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Agricultural Research Institute

PUSA

“ The Highest Cocoa Value
Obtainable.”

PURE BREAKFAST

^oeocu>

‘‘One of the Choicest Items on
Nature’s Menu.”

316153

Cocoa

A combination of FRY’S PURE COCOA and
Allen and Hanburys* EXTRACT OF MALT.

‘Excellent. Its dietetic and d'^as'ive
value is beyond dispute.”-—

K".: «.s of the Profession are cordially inviJ.'* t' vrite for

Samples to-

J. ii “RY & SONS, irTD., BL IS iO'

U GRANDS PRIX, GOI D MEDALS,

ADVERTISEMENTS

MALTINE

RegapMng

“ MALTINE

Professor CHITTENDEN
(Yale University) reports : —

" The results demonstrate conclu-
sively the far greater diastasic value
of your preparation, and enable me
to state, without any qualification
wh|t6ver, that Maltine ’ far
exceeds in diastasic power any of
the preparations of malt which I
have examined.”

ImUoations i—

(1) As a nutrient in feeble nutri-
tion and wasting disease.

(2) As a starch digestant to aid
feeble amylaceous digestion.

(3) In fever and milk diets, to
supplement nutrition and prevent
coarse curdling.

(4) In Infant Feeding, to humanize
cow’s milk.

(5) As a vehicle and emulsifying
agent.

(6) As a natural counteractant
to constipation in infants and
children.

(7) As a galaetagogue.

In preseribingr, please specify

‘ MALTINE”

with COD LIVER OIL

The “ BRITISH MEDICAL
JOURNAL " states :

“ Apart from its own dietetic value,
‘ Maltine,' when combined with
Cod Liver Oil, certainly enables the
latter to be taken by persons who
can neither swallow nor assimilate
it in any other form.*’

POINTS:

Absolute Palata-
billty.

A satisfactory
content — 30 per
cent, by volume—
of Cod Liver Oil.

Easy Digest!*
bllity.

High Food Value
(due ta-4lwr-Dod
Liver Oil being
rendered entirely
available by the
organism as well
as to the nutritive re*enforcement
supplied by the reconstructive
constituents of the ** IVtaltine.”

“ MALTINE COMPANY/’

THE MALTINE MANUFACTURING COMPANY ltd.

— : : rr X,OMl>ON ==

Will be pleased to send Specimens Free of Charge to Medical Men.

f FIFTY YEARS’ .REPUTATION — -k

' ' ' A‘ * ^ ’

HUNYADI JANjOS has now been prescdbed ,
by Practitioners of all countries for , half a
century, and their unanimity concerning its
supreme excellence is strikingly displayed in *.
the emphatic verdict of approval which has
been returned by Doctors the world over.

Ennyadi Janos

Natural

Aperient Water

When we find men of such undisputed
eminence in their several lines as Professor
Virchow; Professor Moleschott, oi’R.ome', Profes-
sor von Esmarch, of Kiel; Professor Lomhrosofr&t
Turin; Dr. Chas. Fauvel, of Paris; Professor
Fred, T. Sayre, of New

A. Hammond, late Surg.- *
Gen. of the United States Army; Professor
von Bamberger, of Vienna ; Professor Vanlair, of
Liege, referring to HUNYADI JANOS in
warm and even enthusiastic terms, nothing
more is needed to show that, ia point of
medicinal qualities, it must be something
^ quite out of the conimon.

PROPRIETOR OP THE SPRINQS—

ANDREAS SAXLEHNER, BUDAPEST.

Samples and Ulterature Free to Medical IVten on application to the .

LOHDON Agency : Trafalgar Buildingc, Charing Cross, W.G. <

L ^ J

ADVERTISEMENTS

[r ~1 SUMNER’S linn

Combined Instrument
and Dressing Cabinet.

34 inches high, 18 inches wide, 1 1 inches deep.

A most useful and ornamental piece of furniture for Surgery or
Consulting Room.

PRICE,
including
Dressings,
etc..

The upper portion Is a well-made '
with glass front and sides, three glass shelves, plated lock and hinges*
The base or lower portion is of metal, and is divided into
eight compartments to hold boxes of Dressings, 6cc. The boxes are
dust-proof, and made of strong cardboard, to which tapes are attached
to facilitate their removal from the pigeqn holes.

The Dressings usually supplied are Boric Wool, Cyanide
Gauze, Alembroth Wool, Bandages, Muslinette (Waterproof Material)^
Absorbent Gauze, Absorbent Lint, and Adhesive Plaster on reels,
but of course these can be varied as desired.

When Dressings are exhausted, they can be replaced, if
wished, in new cardboard boxes at a trivial cost.

R. SUMNER & CO., LTD., LIVERPOOL,

ADVERTISEMENTS

Modern |ViiDWIFERY BAG

and '

Improved WITH STERILIZER.

The bag is made of cowhide (either black or brown) and
has a compartment beneath into which the Sterilizer fits.

The Sterilizer has no seams, being blocked out in one
piece from a,.salid slieet and heavily nickel plated.

. The larger instruments are carried in Sterilizer, the top
portion of the bag being reserved for Nail Brush, Tamp,
Chloroform Bottle, Pill and Medicine Bottles, Dredger, leaving
room for Apron, Gloves, &c.

The inside Cover has loops arranged for carrying the smaller
-instruments.

Price of the Bag, together with Sterilizer, Tamp, Nail
Brush in plated case, Minim measure in case, Chloroform Bottle
in plated case, Dredger, 3 Pill Bottles, 3 Medicine Bottles.

£3 10 O net (or £4 4 0 if of solid leather throughout.)

An outside Canvas Cover can be supplied at 7/6 extra.

R. SUMNER & CO., Ltd.,

SURGICAL INSTRUMENT MAKERS, LIVERPOOL.

ADVERTISEMENTS

“PUTTEE” LEG BANDAGE

FOR VARICOSE VEINS, etc.

THESE are clastic Bandages fitted with a
loop for the foot, and fastened at the top with
patent spring fasteners.

The advantage is that the
bandages are quickly adjusted, and always
keep in position.

They are preferable to an Elastic Stocking
as they can be adapted to any required pressure,
and are cooler and lighter in weight

They require no fitting and are only about

half the price of stockings. '

WE MAKE IN TWO SIZES,

To reach the Knee (9 feet by 2| inches), 2/- each.

To reach the Thigh (13J feet by 2i inches), 3/-' each.

SPECIAL SIZES MADE TO ORDER.

R. SUMNER & CO.. LTD..

LIVERPOOL.

ADVERTISEMENTS

vii

Apparatus for Intravenous Administration of

Salvarsan or Saline Infusion, &c.

The difficulty of keeping a solution
at an even temperature during admin-
istration, led Mr. Arthur J. Evans,
F.R.C.S. Edin., Hon, Surg, Liverpool
Stanley Hospital, to design a flask on
the Dewar principle, which has proved
very successful-

The inner portion has a capacity of
500 c.c. and is separated from the outer
by a vacuum.

Warm fluid allowed to stand in the
flask loses only 3°F in half-an-hour, so
that in the ordinary time taken for
administration, only 1°F is lost.

The apparatus is well adapted for any
purpose in which it is necessary to intro-
duce warm fluids into the body, via the
veins, tissues, or rectum, without the
cumbrous method of keeping the solution
warm by means of spirit lamps, water
baths, etc.

PRICE (including stand, tubing, clip and special needle designed for direct introduction
into the vein without making an incision), 25/-

viii

ADVERTISEMENTS

ASEPTIC

n BESSIMG T ABLES CABINET

This table is made from the best cold drawn steel tubes, and
japanned with white enamel in stoves at a temperature that
renders the surface hard and lasting.

THE PRICE IS EXCEEDINGLY MODERATE.

Measurements of Table'; — Height 32 in. ; Width 22 in. ; Depth 17 in.
Measurements of Cabinet : — Height 13 in. ; Width 22 in. ; Depth 17 in.

The top is plate glass, the underneath shelf and cabinet are
made of metal. It is provided with a bowl for antiseptic solu-
tions, and is mounted on rubber wheels. It is an ornamental,
useful and much desired addition to any surgery or consulting
room.

R. SUMNER & Co., Ltd.,

Surgical Instrument Makers,

I — 1 LIVERPOOL.

so MUSUNETTE APRQIP and COATS for Surgeons & ^uchenrs,
^ OVERALLS for PK^dans in Attendance on Infei;ti^ Cases.

ADVERTISEMENTS

JMNER

Ltd. LIVERPOOL

ADVERTISEMENTS

New Steani'Pressure Sterilizer
I I for Dressings I i

Dressings at short notice.

To attempt sterilization of Dressings toy toolllng is
open to grave objections ; first It is very doubtful if the
beat reaches to their interior, or if it does so, whether it
is of sufaoiently high temperature to klU organisms.
Again, the Dressings are rendered so wet that their
application is unpleasant and objectionable,

With this Stektlizeh these objections are obviated,
as the super-heated steam is passed directly through the
Dressings, which will be found practically dry when the
sterilization is complete.

It is hardly necessary to point out to the modem
Surgeon the importance of having absolutely sterile
Dressings, even for the smallest operations.

The Apparatus, which is easily worked, and is
perfectly safe, is made of strong brass, nickel-plated,
and is sutipiied with a nickel-plated Bteiulizing Bo3t»
which holds the Dressings.

. The steam is generated from a water tank beneath
the box by a wlcfcless sjiirlt lamp, and can only escape
by passing through the Dressings, thus ensuring their
perfect sterilization.

When the process is complete, the box is hemetb
cally closed by turning the Rd, and putting the p ug,
haiiging by the chain, into the hole at the bottom of the
box.

To prevent steam getting into the room, attach a
piece of rubber tubing to the outlet C, and carry It into
a basin of water.

Full

Directions for Use
sent with
each Apparatus.

Steaiiziug
Outlet for steam.

Channels showing how sten m
ascends, passing into holes
in the box, through the Dress-
ings, and out of bottom of
box at E, escaping at G,

H Lid to Sterilizer.

K Screw clamp.

T Thermometer.

W Water Tank.

Mg . IL— Sterilizing Box.

Fig. III.— Section showing Box

IN SITU, El’a

Price : £3 7s. 6d. net.

R. SUMNER & CO. LTD., UVERPOOL.

ADVERTISEMENTS

SUMNER’S TRIAL LENSES.

No. l,-~Set in polished Walnut Case, partitions fox* the rcception’of Lenses; Lenses mounted In
solid nickel and gilt rings, with handles and screw joints,

Dimensions of Case -ISj by 11 by 25 inehcs.

PitiOE:— ©6 108. Od- nott.

Contents :-~30 pairs Convex Spherical Lenses, 0*25 to 20 D ; 30 pairs Oonoave Spherical Lenses,
0*25 to 20 D; 20 Single Convex Cylindrical Lenses, 0*25 to 7 D; 20 Single Concave Cylindrical
Lenses, 0.25 to 7 D ; 1 Blank Disc. 1 l^inhole Disc. 2 Stenoptio Discs ; 1 White Glass : 1 White
Glass, half opaque ; 1 Blue Glass; 2 Smoke Glasses; 1 Ruby Glass; I Double Cell Trial Frame,
adjustable for pupillary distance and height .of bridge.

No* 2.— Set, specially intended for the requirements of SCHOOL MEDICAL OFFICERS, fitted
and finished in same manner as No. 1.

Dimensions of Case ISJ by 11 by U Inches.

Price :—£5 Os. Od, net

Contents:— ' 1 pair each Convex and Concave Spherical Lenses, 0*25 *0*5- 0*75 -1-1*25 -1*5-
1*75 - 2 - 2*5 - 3 - 3*3 - 4 - 4*3 - 5 - 5*5- 6 - 7 - 8 - 10 - 12 ; 1 each Convex and Concave Cylindrical Lenses
0*25 - 0*50 - 0*75 - 1 - 1*50 - 2 - 2*5 - 3 - 3*5 - 4 ; 2 Prisms 2® 4® ; IBIank Disc ; 1 Pinhole Disc ; 1 Stenoptio
Disc ; 1 Double Cell Trial Frame, adjustable for pupillary distance and height of bridge.

R. SUMNER & CO. LTD,, UVERPQOL.

ADVERTISEMENTS

xii

Hot Water Heater or Geyser

for Surgery or Consulting Room

Hot water for Surgeries or Consulting Rooms
is almost an absolute necessity, and this apparatus
has been specially designed for the purpose of
supplying it.

It is fixed over a hand basin, to which cold
water is attached, and which durij^g , ^ogress
through the heater can be raised to a temperature
of 160®F by a>d of a gas burner.'

The water enters at the bottom into ,a narrow
cylindrical shaped container, which is provided
with gills, having the effect of radiating the heat
from the burner to the walls of the container, thus
utilising the maximum amount of temperature
given by tbe flame.

The Heater is entirely constructed of copper,
the water and gas-ways being heavily tinned, and
the outer case is nickel-plated, so'that it harmonizes
well with the general appearance of surgical
appliances.

The output depends upon the temperature of
the water drawn. If the water is raised to 43^F^
above the supply water, the output will be half a
gallon per minute, and this at a gas consumption
of about half a cubic foot of gas.

Price : £3 10s. Od. nett.

Hypodermic
Steritizing Bottle

The Syringe, a 20 minim size, is suspended together
with six needles in a glass tank 3i by inches. The tank
has a bayonet-pointed metal cap, lined with a special
washer which makes it quite water- or spirit-tight. The
Syringe and Needles can therefore be kept ready sterilized
by suspending them either in Alcohol or a solution of
Cresol, thus saving the operator the necessity of boiling
the instrument each time it is used*

It has a strong outer Metal Nickel-plated Case in
which it is very securely carried.

Price: 15s, each.

R. SUMNER & CO. LTD., LIVERPOOL.

ADVERTISEMENTS

XVll

X-Ray Api^aratas

Single-Impulse Outfits

Instantaneous

Installations

Rotating High-Tension
Rectifiers

SIEMENS

BROTHERS & Co. Ltd.

CAXTON HOUSE, WESTMINSTER, LONDON

ARE THE

LARGEST MANUFACTURERS

ALL ELECTRICAL APPARATUS

USED FOR

ILECTRC MEDICAL PURPOSES

Electro-cardiographic

Apparatus

Clinical Temperature
Recorders

Medical Boards for
all purposes

Hospital Ward

Signalling Outfits

Diathermy Apparatus

Dental Motors

Tantalum Surgical and
Dental Instruments

Ozone Apparatus

Light Baths

Radium Etc.

Price £l 15s. ;
or witli camera and
tele-plioto lens,
£10 15s.

DeicrlpUt'e IBroclmre
Post Free,

Europe,

, I saw a bee m a holly hock gafcheuin^ l«illen and stowing itaway.’''^.4 Correspfuutent,

•» iv® *•’**1® tio recognise plants growing on a wall a quarter of a mile away.” — The Oanlen,

Magnifioalion of 43 diameters was obtained and Jupiter dnd his moons were seen with astonishing
clearness.”— A'noH7eJ<7«. .

contrast, definition, flalneSa of field and wide angle; stereoscopic effect
remarkable.”— ASrjt'Hi’c

F. DAVIDSON & CO., 29, Great Portland Street, LONDON, W.

ADVERTISEMEN TS

SANITAS ELECTRICAL Co. Ltd.

Specialists in X-RAY and all ELECTRO-MEDICAL APPARATUS.

The New Earth-free “MULTOSTAT/’

The only apparatus for the practical uses of the Medical Man, with
TRUE Galvanic current, and free from ail possibility of earth
shocks. It provides the following approved methods of treatment :
GALVANISATION. Ionic Medication, Electrolysis, Leduc Intermittent Continue
ous Current, Obesity Treatment by means of the apparatus by Doctors
Bergonie-Nagelschmidt, etc.

SINUSOIDAL-FARADISATION.

GALVANO- SINUSOIDAL FARA-
' DISATION combined.

SCHNEE 4-CELL BATH.

HYDRO-ELECTRIC BATH.

LIGHT & CAUTERY. Separately
or simultaneously, without
the slightest influence of
either. ^

AIR DUMPS for Zabludowski
j, treatment and for the ear,

; VIBRATORY MASSAGE.

‘surgical operations with

, all kinds of burrs, trephines, 'vvrite for “THE NEW BOOK OF THE NEW
f etc. MULTOSTAT,” Post Free on reqite$t,

CEjNXRIPUGES, FANS, etc. Latest TesUmoniah,

More than 5,000 IN USE IN HQSPITALS ani CONSULTING ROOMS.

/‘SANAX^X-RAYOUTFIT. Universal
apparatus for all X-Eay work, skiu

0 therapeutic treatment, screen-

1 examination, flash, instantaneous,
^ tele- and time-exposures and ^
>. tensified Therapy for Treating the
. peeper parts of the Body (the re-
sults obtained are published in the
current'medical journals and have
proved the unsurpassed efficiency
of the ‘ ‘Sanax’ ' X-Ray Outfit). The
“Sanax” X-Ray Outfit can be used
for all the different purposes with-
out any alterations whatever.

SPECIAL DENTAL OUTFITS,

^HIGH FREQUENCY APPARATUS.

DIATHERMIC APPARATUS, for Dia-
thermy and Cold Cautery.

QUARTZ LAMP,

ARTinCIAL MOUNTAIN SUN.

LIGHT BATHS AND LIGHT CURE
APPARATUS.

IONIC MEDICATION OUTFITS, with
the latest improvements. Also
Special Set for Dentists.

OBESITY TREATMENT by means of
the apparatus by Drs. Nagel-
schmidt-Bergonie, which can be
attached to the “Multostat.”

VIBRATORY MASSAGE APPARATUS.
Electric Hand Vibrators.

ALL KINDS OF BATTERIES.

ACCUMULATORS FOR CAUTERY
AND LIGHT.

PHYSICAL EXERCISE APPARATUS.

Velotrab” for horse-trotting and
cycle movements. “Hellas” for
rowing movements. “ Active ” and
“Passive” Universal Orthopssdic
Apparatus.

DESCRIPTIVE CATALOGUES ON REQUEST*

61 , NEW CAVENDISH ST., LONDON, Iff.

Works : 9 and 10, BENTINCK MEWS, W.

ADVERTISEMENTS

COX’S X-RAY AND
ELECTRO'MEDIGAL APPARATUS

OP EVERY DESCRIPTION.

Full particulars and complete estimates for
Hospitals, Hydros, Medical Institutions, Nursing
Homes, and Private Practitioners furnished
on application. Correspondence invited.

, , m

HARRY W. COX & CO. LTD.

ACTXTAL MANTJFACTXJBEBS.

47, QRATS INN ROAD, LONDON, W.C.

Contractors to the Wax OfiBce, 'Admiralty, India Office, Colonial Governments,
and the Principal Hospitals at Home and Abroad. — --r—

AGVBRXtSEMBNTS

xxi

IONIC MEDICATION

FOR

THE GENERAL PRACTITIONER

SPECIAL ( ‘'lOHIC MEDICATION IN
PUBLICATIONS GENERAL PRACTICE.”

FREE ON REQUEST.! “IONIC MEDICATION in DENTISTRY."

60 8c 40 pages each respectively, descriptive of technique and clinical data,
— ALSO —

GENERAL CATALOGUE

250 pages, describing and illustrating every hind of
X-Ray and general Electro-Medical Apparatus.

THE CAVENDISH ELECTRICAL CO. LTD.

130, Great Portland Street, LONDON, W. .

ADVERTISEMENTS

GEO. BARTH & CO

.54 POLAND STREET. LONDON W.

Makers and Patentees of

. Improved .

Anaesthetic Apparatus.

AbVERtiSfeMENtS

“HAEMORRHOIDS.

PRICE

PER DOZ.

PRICE

PER GROSS.

Suppos. Bismuth Subgallat.Co.

Bismuth subgallate is non-irritant, antiseptic, and in conjunctign
with Resorcin, Zinc Oxide, €rc., in the form of a suppository,
has been found most beneficial (even in advanced cases) in the
treatment of haemorrhoids.

LEDGER CARDS for Medical Book-keeping.

v' eimiiLiMHii C w#«cw»»»vr Q

CS P owtasme Q

A Year’s
Record

Glance.

iiiiji. III! Hill nil mil II Ml

Sample

application.

These cards have the advantage of combining Day Book,
Ledger, and recording prescriptions or treatment on one card.
A card is allotted to each patient, and a complete record of a
^year’s account can be kept on one card.

Price: 1000, 17/6 ; 500,9/-; 100,2/-

FttU particulars of same, also of Cabinets for filing same, will be sent

on application,

REYNOLDS & BRANSON, Ltd.

Telegrams:

“REYNOLDS, LEEDS,"

LEEDS.

Telephone
No. 60

xxiv

ADVERTISEMENTS.

THOROUGH ROOM DISIHFECTION.

As described at the Leeds Congress of the Sanitary Institute, 1897, and
at the Meeting of the British Medical Association at Edinburgh, 1898.

ALFORMANT "B ”

By means of this I^amp Scliering’s
Dry Formalin Tablets can be converted
into free Formic Aldehyde Gas.

In Tuberculosis, Whooping Coxigh,
Influenza, and all infectious Diseases,
one Tablet should be placed in the
outer pan frequently during the day,
and allowed to gasify slowl}^

This Lamp is an excellent Deodor*
izer, and should be used in cases of
foul-smelling Ulcers, Gangrene, etc.,

By Royal Letters Patent.

SCHERING’S PURE FORMALIN

(Forty per cent.)

' Clean, effective, non-poisonous ; most powerful Disinfectant and

Deodorant.

Onb GAiyi^OH added to Thirty-ninb Gau.ons of water makes
Forty GAnifONS of a Powerful* and unequalled Disinfectant
and Deodorant Fluid.

Sghering’s GLUTOL (Dr. SCHLEICH)

Is the ideal antiseptic in the treatment of fresh or infected
wounds, forming a firm scab in a short space of time.

For literature a?id particulars apply to

CDe I'ormalin Bpalenlc Co.,

LTD.,

3, Lloyd’s Avenue, LONDON, E.C.

ADVERTISEMENTS

XXV

Rogers’

Standard

Sprays

Ensure the highest benefit from spraying
treatment of Nose and Throat. They
include a number of scientifically de-
signed Instruments for

NASAL, PHARYNGEAL,
LARYNGEAL and
POST-NASAL use

with oily, watery or spirit-
uous solutions and are

UNEQUALLED IN
RELIABILITY,

ROCERS’ No. I SPRAY
for Nose or Throat .

ROGERS’

Kloram Inhalers

are simplest and best for the pro-
duction and administration of neutral
Chloride of Ammonium Vapour.

Full particulars of
Rogers’ Sprays,
Atomizers, Nebulizers,
Inhalers, Syringes,
etc., with a useful
selection of formulse,
posted to medical
men on request.

^ROGERS’ LARYNGEAL
AQUOLIC ATOMIZER.

ROGERS’ POCKET KLORAM

FRANK A. ROGERS,

Pharmacist and manufacturer of Medical Sprays,

327, OXFORD STREET, LONDON, W.

Telephones Telegreme {" London."

XX vl

ADVERTISEMENTS

NEW PATTERN VERTICAL

DRESSING STERILIZER

TN this Sterilizer are einliodied all the latest improve-
ments, and the results obtained arc absolutely
satisfactory, and constitute an advance on those of
higher priced instruments. On completion of Steriliza-
tion the Dressings will be found perfectly dry. it is
equipped with Ejector with Com-
bined Vacuum and Inlet Valve,
Combined Pressure and Vacuum
Gauge and Safety Valve, The
Ejector gives a Vacuum of 8 in.,
a result hitherto seldom, if ever,
obtained in a sterilizer working, as
this does, at a pressure of 1511.).
per square inch.

The Inner and Outer Jackets
are of heavy gauge solid drawn
copper tubes, rivetted together to
an annular gunmetal ring.

The Lid is fitted with a special
metallic joint, undercut into itself
and cast in under pressure, and is
hinged ; while a special pattern
Lever Handle of sufficient length
to avoid any risk of scalding the
operator, provides an easy means
_..gOf raising it. This Lever, being
provided with a stop at back, swings
clear of the Lid while open. The
fly-nuts for securing the lid arc heat
insulated. All fittings and caslings
iircof be.stgijijmctal, Inily niar))incd
and faced, and all materials ami
workmanship are of the best of
their respective kinds.

Inner Chamber in<'.asuros i-o
by 9iin.

liuUt and equipped for Gas
or Steam, complete
with two Nickel-plated
Drums dSSSS

New Pattern Horizontal
Type, with all the latest
improyements, giving
10 in. vacuum and 151b.
pressure. Inner Cham-
her measures 22 by 15 in. Built and Equipped for Gas or Steam ...
Specification and Particulars on request

ALEXANDER ^ FOWLER,

Surjrical Instrument Makers to the Royal Infirmar3%

Royal Southern Hospital, and other Institutions.

104, Pembroke Place, I^IVERPOOZ,.

TELEPHONE 1330 ROYAL.

ADVKRXJSEMExNTTS

xxvii

THE STANDARD

AUSCULTATION SET

(TKSKE’S PATENT).

S/MPUOITY,

BFFIOIBNGY,

PORTABILITY,

THE SET consists of a CHEST-FIECE
and a BINAURAL ATTACHMENT.

The former is a inoclilieation of
the inventor’s orifjinal Stethouoscopo
(patented in ISDG), uml combines in itself
the uses of throe different instruments :
an ordinary Stethoscione, an iiitcusified
Stethoscope, and a PnoneiuloHcoije, as
fu ly explained and described in the
iiiimsH Mkdioai. JoujiKAL, of Nov. 15th,
p. :17 ; and Lanckt, of Deis, (itli, p. 15.

The Standard BINAURAL Is the
only one haviiif? a iierfoct means of
a<ljastnicnt, enablinpi' it to be worn with
comfort by any user, lly simply tnru-
ins the }arf?er of the two circular mits
shown at c, thi? strength of the spnnjc
can be Increased or lUminished: the
smalltn* nut will fix the larger one
p irjnanently. Tins ear-tips Iheinselves
Having a universal joint can be fixed at
any angle roiiuircd.

The Chost-pioce (EiV/. 1), can ho sup-
plied with a joint at b.

Full Dm'rhffhni aiui for

2}romi>(tii J'oni'ordcd on itppUi'olinii.

Cinoe oFP

Clos&o

End Uicws or Hanolis,

Price 27/6

TESKE’S Improved

TONSILOTOME

(MACKENZIE’S PATTERN).

Simpiiciiy >- Efficioncy
Pofiabiiily,

Tliese a,ro the threii <iualities tha.t
at once dislinguish Teske’s New Ton-
silotome among tbe many fonnsof llwi
instrument now on the market, most
of ilieiii lie.iug too heavy. (,oo bnlkv,
loo eomplicated, or j1l-i)alatuH‘d. 'I'o
eiudde tin* instrument to hi* lield linulv,
it must have widgbt, and this should
Ik‘ 111 the handle ; (he cutting iiart being
light.

'I’he latest ailditbm to Toske'S Ton-
Silotome (iilremly well-known for Ibe
iiorse-shoe shaped detachable Knife
(iulde whlcdi renders H absolutely asi’p-
tie) is a collapsildc irandle, substantial
enough to atVord a tivm griji wlieu in
use ; hut when folded will go easily into
the waistcoat pocket. TJie instrument
may be hud wi till the Hiimo Handle tlxed
in any of the three recognised positions.

A. TESKE, Ltd.

a A. TESKE,

Managini/ Director,

Suraical Jnstrunients,

33 PERCY STREET, TOTTENHAM COURT ROAD, LONDON, W.

'reiefratm: “Tesketome, Ox,, LOEdon.” TekJ^hmr: No. 11139 Central.

ADVEkTlSlSMliNTj^

PHILIP HARRIS ■SPECIALITIES

SPLIN™yATERIAL.

Extremely Lig ht. A Non-Inflamm able Celluloid.

PEXULOID possesses all^ the advantages of celluloid, with none of its dis-
advanti^ges. It is RIGID, LIGHT, and Economical, and
abso lutely NON-INFLAMMA BLE.

It can be used for all purposes
for which an artificial support
is required, from the simple ;

\ fracture of the fore-arm or leg \ '

to the complicated spinal sup- i

port or artificial limb; in fact, ^ i ■

* i there is no practical limit to the

i uses of Pexuloid Appliances i
®*^’'sery. They can be (

J jointed, hinged, or laced. They [

Bf! I can be made in any number of 1

j f parts ; they are quickly applied |

f / and as readily removed. Win- ^

li f I dows for Ventilation can be ar-

- ^ I r ranged, and they cost far less

j \ \ than the usual keel appliances.

J W Pexuloid entirely super-

I j other splint material,

I I being clean, durable, and com-

J fortable. It is perfectly adapt-
I able to the shape of the part,

I does not irritate, and is far

I superior to any substance pre-

Y viously introduced.

IMPORTANT.

Jr Another great advantage
with Pexuloid is the simpli-
city of the requirements for obtaining a perfectly -fitting splint or appliance.
No elaborate measurements are needed, as with other materials, but simply
a cast of the part to he supported, and by our method this is only a
matter of a few minutes.

Experts sent to all parts of the United Kingdom to take casts and *
necessary particulars.

Full Particulars and Prices an atffilication.

It is quite an easy process for Medical Men to take their own casts.

PHILIP HARRIS & CO. u?g. BIRMINCHAHII, Eng.

ADVERTISEMENTS

XX ix

PHILIP HARRIS ■ SPECIALITIES

THE HARRIS

“AUTO” BANDAGE WINDEB.

Patent No. 14208 12.

The “ Auto Patent Bandage Winder is the result of long experiment, and
is offered as a perfect solution of a great problem.

Most bandage winders, prior to the introduction of the "Auto,*' gave
considerable trouble in use and were faulty in design.

The " Auto Bandage Winder is constructed
entirely of metal, nickel-plated, containing a power-
ful spring, which when set (by turning the handle a
few times) has sufficient motive power to completely
wind the longest 4-inch down to 1-inch bandage of
calico, open-wove, or any other material. An effec-
tive brake is introduced into the mechanism, which
allows the operator to control the spring at any
point.

The operator has both hands free (as shown in
the illustration) to untangle the twisted bandage.

We thoroughly
recommend the
use of the “Auto**
Bandage Winder
for —

Hospitals.

Red Cross
Societies,

St. John’s Ambu
lance,

Doctors,

Surgeons,

Etc.

PRICE.~»-

The Harris “ Auto'" Bandage Winder (Patent No. 14208/12), Nickel
Plated, and strong clamp for fixing on to any shelf or table . . . 22/6

- — Special Prices for Quantities. - —

INSTRUCTIONS.

Screw the Winder, by means of clamp, to any suitable shelf or table, push down the
brake knob, then turn handle a few tinies — affix end of bandage to sleeve pin, hold band-
age tightly, release break, and the bandage will automatically pull through your hands and
self wind. On pulling off the bandage, it will be found to be perfectly wound.

May ha sent on approvaL

PHILIP HARRIS & CO. gg. BIRMINCHAM, Eng.

XXX

ADVERTISE aiENTS

PHILIP HARRIS - SPECIALITIES

Apparatus for
Collecting and Applying
Carbon Dioxide Snow.

SEE THE LITTLE MAEUAL:—

CARBON DIOXIDE SNOW: Its Therapeutic Uses. 3iy
Hall-Edwauds, L.ll.O.P., F.R.S. il'.din.), lion. fc.R.V.h.
London : Simpkiu, Marshitll, Hamilton, Kent & (’o., Ltd.
1913. Crown 8vo, pp. 95. 3s. 6 d. net.

SOLE MANUPACrUJf^BRS*

ADVANTAGES : -The Collector not only admits of obtain-
ing, the small and necessary amount of snow for one
treatment without undue A

waste, but it renders it ^ iA

unnecessary to transfer —jiq, I'LiV

the snow from one piece I l\

of apparatus to another. ,, f

The snow is always of ""Te—t — *•

the same hardness and the /

testofcomplete and proper 3 / /

compression is that the '~7^~T “ivfeV “
cone should sink in water. ' ''®\

J'V{/. 9.— Diagi am of Compress- _/
ed Snow, ahowinff broud |j||j'‘
base and cone-ahaped 111 )
jection. The trails verso linos |,
indicate the iiositions for I I

cutting off the cone so as to —

produce a circle of any /---

desired diameter. /

Fi'fi. 10.— The ai>-
pli<*aior show-
i n u cone of
o, omjH'ossed
HiKiw projooi-
iiifr from its
lower end.

The “ Hall-Edwards” Carbon Dioxide
Snow Collector and Compressor.

SET No. I,-

Hall-Edwards’ Improved Bet for producing
COa Hard Snow, coniprlHlruf;— Collector, fitted
•with top and bottom stirrup compresBor
Eiff. 7), Hpecial Rammer and Metal Rods, also
, used for producing compressed small pencils of
hard snow, Hardwood ApiiUcator for holding
cone of snow {nee. Eifj. 10), Special Nipple luid
Union for attaching to Cylinder, The above
atiparatua is made of Llgiimu-Vltn^ ami Dtdta
Metal, nickel plated .. complete )®2 *7 8

SET No. II.-

Same as specification No. 1, but Including a
41b. Cylinder filled with COij, Key and RI(‘,tal
Stand for holding Cylinder.. .. complete £4 6 8-

SET No. ni.-

Same as specification No. I, but including a
71b. Cylinder, filled with COa, Key and Metal
Standfor holding Cylinder.. .. complete £4 13 6

I Full Particulars on Application, and sent
with each set.

PHILIP HARRIS & CO. ffg. BIRWINCHAM, Eng.

ADVERTISEMENTS

XXXI

PHILIP HARRIS . SPECIALITIES

STERILE EHESGENCY POCKET-CASE

CONTENTS
1 Finger Knife

0* HARRIS.”)

1 Fair Spencer Wells
Forceps

•4 II

' Dressing Forceps 1 Pair Scissors 1 Abbey’s Needle Holder

Sharp Hook 1 Silver Probe 1 Director with Scoop

Perforated Needle Box, containing 3 Assorted Suture Needles
Bottle of Silk in Alcohol, with metal screw cap
‘ Dodble Sharp Volkmann’s Spoon
Record Hypodermic Syringe with 2 Needles.

(a) All- the above are carried in case (as illustration), which is
filled with absolute alcohol and is hermetically closed, and no
fear of leakage whatever.

-- (6) The instruments, once sterilized, are always ready for operation
, and in perfect sterile condition.

(e) -The instruments are fitted-in- a rack in such a manner as to
prevent them shifting in transit.

Indispensable for Country Work and Field Purposes.
PRICE, complete .. 42/-

Harris ^

sterilizer

Bags.

' ‘ slo^, of^wliich thi ■, V

sterilizer! occupies 'I'f' >' '''

and yet ^cupiesno i';,. ' ' '■

\ ; space, because it ' ' ■ '

\\ forms the best possible container for the aseptic dvc&sings and

A y'''' instruments wdiich the surgeon reciulres to carry.

\ The slorillzor is made of copper, and has a perfora-
I ted trav, lid, and a wlcklcss two-rose lamp. The

\ \ other division is furnished with a washable tfike-out
» Xv!) \ \ \ lining, and loo])S for bottles, etc. The whole is

A 1/ )1 covered \vith brown or black cowhide, and has excel-

t >^viv5«Sv>K'li \ J lent fittings. Nothing better for all general purposes.

I ' / / Hize closed, 16 by 8 by 5,J ins., complete with

i } Sterilizer 63/-

^ ' The “HARRIS-YEO^’ ~~

IMPROVED INHALER.

(Res'*' Design Mo. 611594/12).

For Treatment of Tuberculosis:—

„ . r^' Dr. Burney Yeo’s Inhaler, which is universally

\ used, is found not to admit enough air. ^J'his is

• ' especially evident when used in those cases where

raild respirations, cough, dyspnoea, and the accompanying cardiac embarrassments, are
proh incut features. These symiitoms were usually much increased by the obstruction which
was offered to the respirations by the closed inhaler. The illustration shows “ A ” out away and
acts as a ventilator, which not only brings about better results, but Is much more comfortable
to use. The lid ** B ” takes off to enable the patient to remove’ once or twice daily to be cleaned,
thus cap “ B ” also prevents the inhalant trickling down the aide on the patient’s face.

“Havrls-Yeo” Improved Inhalers (Regd. No. 611591/12) .. Per dozen 12/- net.

PHILIP HARRIS & GO. ,!?£ BIRMINGHAM, Eng.

XXX ii

ADVERTISEMENTS

THE

REPELLO

(ZEAL’S

patent:

No. 1959:

CLINICAL THERMOMETER

No Shaking Required.

A 30 sec. reset instantly. Made in all kinds.

Kew Certificated. Guaranteed Accurate.

NEW IMPROVED LENS FINDER

The only Easy Reading Magnifying Clinical
Thermometer on the Market.

^ OUT OK KOLUS

The square mark engraved on lens front locates the Mercury immeJiately.
SPECIAL AWARD AND GOLD MEDAL, NEW ZEALAND, 1907.

SILVER MEDAL, INDIA, 1909. , SILVER MEDAL, LONDON, 1913.

Of all Instrument Makers, ChemIstS) &c.

Inventor and Patentee!

G. H. ZEAL, 82 , Turnbull St., LONDON, E.C.

Wholesale Manufacturer of all kinds of Clinical Thermometers.

‘Neboline” Co. No. 21 (in Asthma).

“Neboline” Compound No. 21 (Atropine Cocaine ITydrocliloride
gr. 2 ill each oz.) conveyed in a unique degree of aiomi.satiou by means
of the “Aeriser” or “Universal Vaporiser,” quickly averts the par-
oxysnivS of Asthma. This preparation, which has a very extensive
sale in the United vStates, was the subject of couinient in a notable
case before the High Court.

The Leading Council for the Lancet said:

“ OiJpenheimer's are chemists ; they prepare this specific, they sell it to
physicians and chemists ; they sell it only to qualified men, and accompany-
ing the sale is the statement in their catalogue of what it contains.*’

A Policy which Protects the Medical Profession aqd discourages Self-medicatiori.

PRICES: — No. 2 i “ Neboline ” Comp. 3/6 I **Aeriser” .. ,, 6/.

“ Universal Vaporiser” ..12/6 1 Pocket Aeriser .. 4/*

Literature and Liberal Saniides 07 i request.

OPPENHEIMER SON & Co. Ltd. Que en^Vlcg.^ria Stroot,

^ firepuceI^ Modernise Your Fireplace
' in Five Minutes

. From 10/6

] Half the Coal. Houghtoii’s Adjustable Grate

Twice the Heat. 3 SIZES.

j WXX^I. WARM ANY ROOM

-1 TldSTIMONIALS. I

Mkuical Times. S!e>>t., 1913. \

A valuable addition to the side room, especially where
there ia no nii!ht nurse.

'I’lii*'. Briiisii Jouunat. oi.’ TnnEUcui (»sxs. Junf, 1913.

“ Ho apolo(4y is needed for drawing attention to the
Houghton Adjustable Grate.”

Upper Edmonton. County Court Office, Uth Mar., 1913.

“I have had the room up to 150“ by JO in the morning, this I
”r could never do -with the old grate . . . the judge's room
J was the coldest in the building."

“] MISS GllOOM, SlIRKWSRURY.

" It answers perfectly in the bedroom, and if made up late
it not only keeps in all ni^ht, but there is a good fire in
the morning at 7 a.in."

jl/cfiUoa " Medical Ammal" and

On receipt of P.O. deposit we send-grate for actual trial.

Send for X>rs. List.

D ADJUSTABLE GRATE Co. ilford, e.

XXXI V

A D VERTISEMENTS

FOR USE IN BATH and TOILET BASIN

< §ulphaqua

LARGELY AND SUCCESSFULLY PRESCRIBED
IN THE LOCAL TREATMENT 0<-

Skin Diseases, Gout, Rheumatism,

dfec. —

Possesses powerful antiseptic, anti-parasitic, and antalgic
properties. Relieves intense itching and pain, is without
objectionable odour ^ and does not blacken the bath enamel.

SULPHAQUA SOAP.

Especially useful in the treatment of Acne and Seborrlicea of the Scalp,
in Boxes of J and 1 doz. Bath Charges, 2 doz. Toilet Charges, and i doz. Soap Tablets.
Samples and Literature on requesU Advertised only to the Profession,

C D r^OAO/^lTC /iftamifactudnc

1 110 1 • v^JrirV.tvljlJtLo cbemistSt —

ST. HELENS, LANCS.

The High-class Pharmaceutical Products of

The CHARLES H. PHILLIPS CHEMICAL CO.

14, Henrietta Street, Covent Garden,

^ I.ONDON.

Milk of Macnesia

,, [Mg.H.O.,
1 24 }|r9. to
[ 1 oz.

(Registered Trade Mark)

SYRUP OF

Phospho-Muriate of Quinine'

PHILLIPS’

COMPOUND.

SAMPLES AND LITERATURE
SUPPLIED ON APPLICATION,

ADVERTISEMENTS

XXXV

XXXVl

ADVERTISEMENTS

EMETINE HYDROCHLORID.

(WHIFFEN^S)

EMETINE HYDROBROMID.

(WH/FFEN’^S)

FOR h:yfoi>rrivi:i:o i3VjrEi0Ti03sr,

The new remedy in Amoebic disease,

vide ** British Medical Journal,*’ Aug. 24, 1912, pp, 405*408,

We have manufactured the above preparations during
the past 15 years, and they may be obtained by order-
ing Whiffen’s Brand from all Chemists and Wholesale
Drug Houses in the United Kingdom and abroad. —

OuF oihBr Speciai Manufactures inciud/e

MORPHINE AND COHEINE

Other Alkaloids and Preparations of Opium.

* SALICINE, CAFFEINE, NICOTINE, STRYCHNINE,
and all the PRINCIPAL SALTS.

IODINE AND BROMINE PREPARATIONS.

OonffBciora to I#. /If. Govommeni, e#c.^ e#c.

Acknowledged by highest Authorities on Hydrotberapeutics as the

SIMPLEST, MOST CONVENIENT, MOST EFFICIENT

. . . Artificial carbonated Baths for the . . .

NAUHEIM Treatment.

Instantly prepared in any Bath. No damage to baths or fittings.
Trial Bath and Literature free to Professional Men.

The HITGISNIC COMPANY, Ltd.

36 Southwark Bridge Road, LONDON, S.E.

ADVERTISEMENTS - XXXVii

i tWassebmann Test^ i

Conducted strictly according to the

ORIGINAL TECHNIQUE

and with reagents prepared under the constant control of

Prof. Dr. A. v. WASSERMANN

— at the reasonable fee of 15/- each. —

Sterile Collecting tube and Instructions for Collecting
Blood will be forwarded on receipt of communication by —

THE

WASSERMANN INSTITUTE,

SUTHERLAND HOUSE, LLOYDS AVENUE,
LONDON, E.C.

“HERO” WHISKY BY POST.

, /“Hero Liqueur” Whisky was found to be
“riie WOSp##a/”J a finely -blended, fully-matured whisky, with a dis-
S&ys m I tinctive jBavour that is in striking contrast to the

I thin type of liqueur whisky so often met with.

Famed for nearly a Century ar\d supplied Direct at Wholesale Prices.

T o meet the wishes of our Customers and friends who complah. that they are
unahle to get satisfactory snpplie.s of Wines, Sni-tm, E'ic., in the country,
we give uiicloineath p.'iriicul.irs of postage on our specialuies.

We flo a very large and ever-ino easing postal business all over the United
Kingdom. We pack securely, and guarantee safe delivery.

Postage on 1 Bottle 6d. ; 2 Bots. 8d. ; 3 Bots. lid.

PRICE LIST POST FREE ON APPLICATION. Per Bot. Per Dozen.

“HERO” Old Scotch Whisky ... 3/6

“GLENBURN” Old Scotch Whisky (Rcga.) ... S/T 37/- | g 3;

“ HERO” Grand Old Liqueur 1 15 Years Old ... 4-/- 48/- r tt; »

Whisky (Registered) | 20 Years Old ... 4/6 54/- | q

20 Years Old (Blend of Finest Glenlivet) 5/6 66/-

The above Whiskie.s are fully matured from 5 to 20 years in Sherry Casks
and from the best Highland Distilleries direct. A Trial solicited.

CARRIAGE PAID on One Dozen and upwards to any part of the United Kingdom.
CAN ONLY BE HAD FROM—

A. DEWAR RATTRAY, Scotch Whisky Dealer,

188, Dumbarton Road, PARTICK, GLASGOW.

Enteritis

Lactic Ferments

Tablets — Enteritis, Dermatosis.
Pulvi-Lac‘.eol—''^imxa\S&, Otorrhoea.

/ f ELIXIR-AMP.

Chemically pure re-crystallized SALTS— complete absence of sug;ar.

M ■ ■ ■ EXTRACT OF

MipposarcineRoy

■ ■ ! containing

four times more Glycogen, and more Haemoglobin and
Iron than any other preparation.

ccmo

(TASTELESS)

Absolutely Odourless and Colourless CASTOR OH.,

lod^r lodargol

FREE FROM PEPTONE, MENTHOL, OR GLYCOGEN.

NON-TOXIC — PAINLESS.

I TUBERCULOSIS GONORRHOEA

Samples and Literature sent
on request to the Medical
Profession.

Sole Agents for U.K, Colonies
and Dominions : —

M. BRESILLON & CO.

Gamase Buildings,

LONDON, E.C.

Fumigator
Gonin /

Cheap, I

Quick, \

Efficacious,
Disinfectant

ADVERTISEMENTS

xxxix

SCHERING’S

Modern Therapeutics

— IN CONSTANT AND INCREASING DEMAND.—

ATOPHAN

Fundamentally New Therapy m Gout,
Rheumatism, Sciatica, Lumbago, and all
diseases due to disturbed uric acid metabol*

NOV ATOPHAN

and clinical effect to Atophan.

Tasteless form of Atophan
for patients with sensitive
palates. Equivalent in action

ARTHIGON

Clinic, Breslau.

Gonococcic Vaccine for specific treat-
ment of GONORRHOEA complications. ,
Highly recommended by Prof. Neisser^s

MEDINAL

Readily soluble, safe and prompt hypnotic,
without cumulative toxic effects, for inter-
nal, rectal and subcutaneous application.

*T r AT T C A 1 \J Nerve Sedative. Combined action of Bromine
V x-V. J with Valerian, Is readily taken and well borne.

HORMONAL

and Intravenous injections.

HEGONON 1

with Valerian, Is readily taken and well borne.
Produces no eructation.

A T Peristaltic Hormone for the treat-
ment of Chronic Constipation and
■ Intestinal Paralysis. Intramuscular

r IT TV T T\T A “still better” silver preparation for

the local treatment of Gonorrhoea. No
caustic action, readily soluble in water,

T TD most effective urinary

V-J XVV-/ X XVV-/X ilNl antiseptic. Highly recommended in
III* " m mimmmm Typhoid Bactcriuria, and as a prophy-

lactic against the spread of Typhoid Fever.

ETA-EUGAIN (HYDROGHLOR^. AND

* ■ Local Anaesthetic, identical

with Cocaine in anaesthetic action. Toxic effects reduced to a mini-

BETA-EUCAIN

CTTUT AA/TTIVT (Merguric-sulphate

OU JDJU/ViVlliN ^ ^ ETHYLENE-DIAMINE),

Non-Irritant, Non-Corrosive,

^ Substitute for Sublimate, with greater penetrating power.

Samples and Literature on application to

A. ^ M. ZIMMERMANIM

3 Lloyd’s Avenue, LONDON, E.C.

M.A.S

ADVERTISEMENTS

ALLIANCE DRUG & CHEMICAL Co.

34, ieadenhail Street, LONDON, E.C.

iE9ta.blishecl 1812. Rcorgfanlscd 1002.

The Company specialises in providing the Medical profession at the lowest
Ijossible inclusive prices (no charge for Bottles, &:c., or Oases, &c.), 'vvifch pure
reliable Drugs, Chemicals, riiarmaceiiticiil Preparations, Compressed Tablets, rills,
Surgical Dressings, and Stock Mixtures of approved Formuhe as used by the London
and other Hospitals.

We append a few sample prices for guidance of the great saving that can be
effected, and earnestly ask our Keadera to kindly forward us their professional card,
when we shall be moat pleased to forward iM)sb free our

DETAILED PRICE LIST

wliitrh is issued twice a year, and extends to 32 pages, including many sundries in
constant demand, and will give full particulars. In many instances our Clients
have written us stating we have saved them

40 per cent

of their usual Yearly Account for Drugs. This saving is not reflected in the quality
oi our Goods, but is primarily due to not employing TRAVELIjERS, thus saving
the purchaser the cost of tne Tmvollers’ Salaries and expenses, which greatly
enhance the pi'ices the usual Drug Houses have to charge.

Note.— Only Terms : Net Cash with order, without discoimt ; or orders rcceivt^i
through London Merchants or Bankers. Goods carriage forward. All packages
free. Export cases extra. Special terms for Export oixlers (see List).

OUR DETAILED PRICE LIST

is now ready ; if a copy has not been sent you, plea.se send
professional card for same.

At per lb. At. pov lb,

Ijif. Aurant. Cone., 1 to 7 .. 6 lb. 1/3 Inf. Gentiainc t.'o., I to 7 .. .. 6jb. 1/1

,, Aurant, Oornp. Coiio., 1 to 7 .. „ 1/3 „ Quasslre Cone., 1 to 7 .. .. „ -/G

Huchu Cone., 1 to 7 .. „ 2/2 lihe! Cone., I to 7 .. .. ,.1/6

„ Cahunbnn Cone., 1 to 7 . . . . „ -/ll „ Rosed Acid. Cone., 1 to 7 . . „ i/s

„ Cavyo)ili. Cone., 1 to 7 .. .. „ ii- „ Sene!i<a3 Gone., 1 to 7 .. .. ,, 2/1

CascariUa Cone., I to 7 .. „ 1/4 .. Valerian Cone., I to 7 . . ,, 3/3

„ ClnchoniB Acid, I io 7 . . .. „ 1/7

^ At per lb.

hill. Aconiti Meth. a Ih. 1/2

1 lb. 3/6

„ Rellad. Moth ,*> lb, 1/6

1 lb. 1/8

Lin. J5.P. ..

„ .Saixj IVlctli. ..

„ Tm*b, Acet., IJ,!*.

At. )it>r Ib.
.. 40 1b. -/ll
1Mb. r-
.. -/7

.. TMb. 1/-

At per lb.

1 dq. Anuuonil Acetatls Cone,, 1 to 7 G lb, -/8
1 lb. -/lOl

„ Amrnon, Aroinat G ll>. -./G

,, Arseniealls, B.C. .. 71b. -/I

1 Ib. -/7

„ Asenii Ilydrochlor., r,B. .. 71b. -/4
„ Bismuth, P.B. . . , , G lb. 1/1

Llq. TocR Port, B.P.

„ Mori)hlntt> Acet. or UyrtrO'
chlor, B,l'. ..

„ OpilHod

.. Btmnbi Subacet., IMl.

„ Pruni Virfj;. p.s. 1 to 7
„ Rhoe>a(lo.s pro syr., 1 to 7

Gib. 2;Q
fMb. 4/2
7 11). -/3t
Sib. 2/2
Dll). 1/n

Tinct. Belladou
„ Benzoin
„ Camph. Co.
„ Card. Oo.

„ Gentian Co.

B.P. Aquos.

2/11 1/- Tlnet. Hyosevam

3/6 — „ NucIrVoui.

2/5 1/1 „ Opil ..

2/8 V- M Quin. Amon,

1/lM 1/- „ RheiCo.

PILLS, TASTELESS COATED TABLETS, COMPRESSED

P( itass Broinid , P.B.

M lodid. P.B.

Soda Salicyl Pulv., P.B. ..

,, Phys. pur. ..

Soda Sulphfis Feathery ci yst.
Sp. .aStberNit. P.B.

Sp. Amon. Aromat. P.B. . .
.Syr. Cascara Aromat. P.B
Syr. Glyeero-Phosp. Co. ..

At i)er lb.
. 71b. 1/9
. 3 Ib. 12/-
. 71b. 1/5
11b. 2/4
. 7]h. -/2.i
4.i 11), 3/7^
1 lb. 3/10
. .T lb. 2/10
. fill). 1/2
. 6 lb. 1/61

Ung. Acid Boric, Flav.

„ HytlrargP.B.

„ „ Amon. P.B.

„ IchthnmolisB.P.C. ..
„ Elnci 0.\. l\B.

Vin. Ipecac. P.B.

At per lb,
28 lb. pail -/4'.

.. 711). 2;-

1 lb. 2/3
.. 71b. 1/2
.. 71b. 1/5
.. 711). -/9V
.. 51b. 1/8

Minmvm qumtily at th/ tte tirurtt. Home Tnuhi
3 Exjport, 12 WinclmUr Qunrh

ADVERTISEMENTS

xli

SPERMINUM-POEHL

A natural constituent of human organism, effects the oxidation
of the products of the regressive metamorphosis, protects the
ceils against accumulation of pernicious autointoxications, and
brings the reduced blood alkalescence back to normal, &c.
Favourable results are obtained in cases of Neurasthenia,
Nervous Debility, Senility, Hysteria, Diseases of the
Heart (Myocarditis, Fat Heart), Syphilitic Cachexia,
Tuberculosis Tabes, Impotentia in Neurasthenia,
Chronic Rheumatism, Rickets, Gout, Anaemia, &c., and
in all cases of Over-Fatigue and for Convalescents.

ESSENTIA SPERMINI-POEHL is given 30 drops 3 times a day,
i hour before meals, in Vichy or Milk. In serious cases SPERM!-*
NUM-POEHL pro INJECTIONE in ampullae, each containing

one dose.

Manufactured in the Organotherapeutic Institute of

Professor Dr. v. POEHL & SONS, St. PETERSBURG.

Oxygen Hydrotherapy in Neurotic Cases,

Insomnia, Paresthesia, Heart Affections,

effectually obviates the need of depressant and habit-forming drugs
(WiNTERNiTZ, Sommer, Grosse, Dumstrey, Flatau, Tornai,
Schnuetgen)

PEHOGEN BATH

(Sodium Perborate with Catalyzer)

yields effervescing hydrogen dioxide baths evolving 35 pints
nascent oxygen in some 20 minutes. Acts specifically sedative
and somnifacient, producing euphoria and sound sleep. Far
preferable to the Nauheim batli in cardiac processes with high
blood-pressure, arteriosclerosis, asthma, chronic nephritis.
Obviously indicated in skin diseases where H^Oa is used.

Fu/l Particulars and Literature from the Manufacturers,

A. AIMP M. ZIMMERMANN

3 Lloyd’s Avenue, LONDON, E.C.

i\l. A.S.

xlii

A D VERTISEMEN TS

Advances in Treatment.

Messrs. Allen & Hanburys, who are in close
touch with the progress of modern medical
science, desire to draw attention to the follow-
ing products at present widely employed :

XITRFDf^ITI IW requirements in Tuberculin Therapy
1 UD£il\vU Lilli can be met promptly and economically.

A copy of the latest edition of the booTclet entitled “ The Tuberculins,”
with coloured plate showing diagnostic reactions, and complete range
of doses, may be had gratis.

“ANTILUSIN”

The new Serum treatment of Chronic
Gastric, Duodenal and External Ulcer-
ations.

Two forms of Serum are prepared I
“.ANTILUSlNf A” is for use by the mouth.

‘‘ANTir.USIN' B ” is employed as a local dressing: for ulcers of all
kinds, and for suppurating wounds and sinuses.

“POLYGLANDIN”

A solution of the autacoid prin-
ciples of ovarian, testicular, pit-
uitary, thyroid, and parathyroid
gland substances.

‘ Boly eland in" is prepared in two forms : for subcutaneous use as
' Azoule " Polyglandin ; for oral use as Eli.\'ir Polyglandin.

“APYROGEN’’ Solutions. Salvarsan, Normal

•iT^ioHark Saline, etc.

Prepared with apyrogenetic, freshly redistillod water,
for subcutaneous and inti-avenous injections.

Solutions for subcutaneous or intra-
II 1.1 w^vrl4 muscular injection.

Trade IMark

The “Hyposol" ainpoule-.syringe (complete with sterile needle in gla.s.s
sheath) i.s the acnie of simplicity as a ineatis of injecting Vaccines,
Mercurial Cream, Calomel, Salvarsan Cream, etc.

A Pamphlet descriptive of any of the above xvill be sent "TPH
on request.

Allen & Hanburys Ltd., London.

We.st Knd House :

7, Vere St., Cavendish Square, W.

City ) louse :

Plough Court, Lombard St., E.C

ADVERTISEMENTS

xliii

Telcminis: "Allkxbijrys, Lomuon."

I'elcphoiit's :

Lombard vStreet— 2954 (two lines) Avenue.
Bethnal Green— 5023 (huir lines) London Wall.

On Sundays, Holidays and after 6 p.m.
TeleAram&: “Vereburys, London."
Telephone : 5437 (three lines) P.yddington.

Sera, Antitoxins, Vaccines, etc.

Diphtheria Antitoxin

Liquid, in vials of 1,000 units, one vial in eahC 1/6
I iiquid, in vials of 2,000 units, one vial in case ‘2/6
Liquid, in vials of 2,000 units, two vials in ca.se fl/-
Liquid, in vials of 4,000 units, one vial in case 5/-
Dried, in vials of 4,000 units, one vial in cose 6/-
High potency liquid, in vials of 4,000 units,
in about 4’5 c.c,, one vial in case . . . . 101-

Diagnosis boxes, with two sterilised glass
tubes and a sterilised swab !/•

Tetanus Antitoxin

Liquid, in vials of 10 c.c., three vials in case 12/-

Ditto, single vials 4/-

{Twelve' vials necessury for a ctiraiive dose).

Dried, in vials of 1 gramme (= 10 e.c. liquid
serum) 4/-

Anti-Streptococcic Serum

(multivalent)

In vials of 10 c.c,, three ^ iais in case . . 7/6

Ditto, single vials 2/6

Diagnosis boxes, with sterilised pipette in

glass tube !/•

lK.vamination of I'us free on nppUealhin to
usen of this serum).

Anti-Meningococcic S$rum

tmultivalent)

In vials of 10 c.c., three vials in case . , 7/6
Ditto, single vials 2/6

Anti -Dysentery Serum (multivalent)

In vials of 20 c.c 5/-

Normal Serum (Horse)

In vials of 10 c.c . . . 1/-

Anti-Plague Serum

In vials of 20 c.c . , . 5/-

Plague Prophylactic

Liquid, in vials nf 1 c.c. . , 1/6

Coley’s Fluid (New)

In vials of ‘2 c.c. . , .

Anti-Scorpion Serum himitivalcni)

In vials of 10 c.c

Staphylococcus Vaccines

Ut) Miulc with UtaphiiloriU’CHH aureus alone.

iur tuvunculoHis and sycosis.

0>) Made witii mixed I'liltnres of fitajihiflo-
eoerttsnureAfi, eitreusandalhus, for acne.

(<') Made with Staphiiloroerits alhus alone.

In vials containing .“00, 1,000 and 2,000 million

cocci respectively, per vial i/fi

Diagnosis boxe.s, Nvitli sterilised pijiette in
glass tube 1/-

Calf Vaccine

Metal caiiillavy vials (one vaccination) each tkl.
Ditto doz. .)/-

Special Acne Vaccine

In vials of three colours.

White, containing 125 million Staphylococci
and 125 million Acne Bacilli, per vial . . 1/6
Amber, containing 260 million Staphylococci
and 250 million Acne Bacilli, oer vial . . 1/6
Beue, containing 600 million Staphylococci
imd .500 million Acne Bacilli, per vial . . 16

Streptococcus Vaccine (multivalent)

In vials containing 2^, 5 and 10 millioa cocci *
respectively, iier vial 3 '0 i

Pneumococcus Vaccine ('multivalent >

In vials containing 2), 5, 10 and 26 million
cocci respectively, ^r vial :*•/•

Cholera Vaccine

In vials containing 500, 1,000 and 2,000 million
cocci respectively, per vial 2'6

Gonococcus Vaccine

In vials containing 2i, .5 and 10 million
cocci respectively, per vial 6'-

Typhoid Vaccine

In vials ci)ntaining500, 1,000 and 2,000 million
cocci respectively, i)er vial 1/6

Bacillus Septus (HofFman)

Vaccine

In vials containing 100, 200 and 400 million
cocci respectively, per vial o/.

Compound Catarrhal Vaccine

In viols containing 20, 40. 80 and 200 million
cocci respectively, per vial 0'6

Influenza Bacillus Vaccine

In vials containing 10, 20 and 10 million
cocci respectively, per vial . . . . . J'V-

Micrococcus Catarrhalis Vaccine

In vials containing ‘25, ,50, 100 and 260 million
eooei respective! j , per vial 2' •

Pneumohacillus (Friedlander)
Vaccine

In viala containing 60, ino and *200 milium
cocci respectively, per vial .. .. .2(6

Tubercle Bacilli

For malting Emulsion for opsonin testing
ill viiils, cacl)

FOR VETERINARY USE.

Tuberculin

In vials of li c.c 1 '■

Mallein

In vials of 3 c*.(‘ I'-

Anti-Tetanus Serum

(For Vetw'inary Use only)
In vials of 10 c.c

SOLE WHOLESALE AGENTS:

Allen & Hanburys Ltd.,

Lombard

Street,

London.

xliv

ADVERTISEMENTS

PNEUMOSAN

(For constituents see The Lancet^ 11/10/13, page 1070) Reg:. Trade Mark

has marked advantages over any other agents employed in the treat-
ment of Tuberculosis. It is not a drastic remedy and hence it will
never cause any harm locally or constitutionally. Some thousands
of cases have been treated with it during the last 3 years and the
results enable us to form the following conclusions : it is practically
infallible in early cases, it is capable to arrest the disease
in advanced cases, and it is palliative in extreme cases. It
is strongly indicated in Pulmonary, Joint and Glandular Tuberculosis,

Extract from an official report issued in June, 1913, by the

Birmingham General Dispensary Tubercnlosis Departm’^t ;

“ 76 cases have been treated with Pneumosan. Of these, 43 improved,

6 got worse, and 27 were apparently not affected. No selection of cases
was made, except so far as it is mentioned below. The injections were
intramuscular and were given twice weekly* over a period of 4 months.

In no case was a local reaction observed. A general reaction was rare,
and when it occurred the rise of temperature was not associated witli
subjective symptoms as is generally the case with the Tuberculin reaction.
Those who grew worse during the Pneumosan treatment are not suit-
able for Tuberculin. 13 patients who have previously been treated
with Tuberculin, but whose extreme sensitiveness renders its contin-
uance unsuitable, were placed upon Pneumosan ; 5 of these improved
but 8 fell into the class of ‘no apparent change.’ By improvement we
indicate increase of weiglit, increase of energy, and a general feeling of
renewed well-being. The time is loo short to talk about cure.”

If the injections could have beoii made in conformity wiili the
for U.se,” the. percentage of “Improved” wot Id have wiy likely risen t(» '!u oi
90 per hundred.— fjy the I^neumo'ian Chi'mincfir^Fahrilt.

October 30th, 1913. The following supplementary roport haw rcjiched us from
the same source : —

**We are testing Pneumosan in a very large number of cases, and the
results continue to give satisfaction. It is practically impossible to get
out-patients to attend more than twice a week, while we have not the
time necessary to visit their homes for the purpose of inoculation.”

PNEUMOSAN is issued in bottles containing 20 to 30 Injections,
Price 15/6 carriage paid to any part of the United Kingdom.
Special Syringe, with two needles, 5 -

Any Hospital in Greater London with facilities to try the drug on
a large number of in-patients may apply for a free supply. — <-

Order direct from the Manufacturers —

THE PNEUMOSAN GHEMISCHE-FABRIK,

132, GREAT PORTLAND ST., LONDON, W.

Telephone : Mayfair 1315 Telegraphic Address : “ Numocon Wesdo, London.”

ADVERTISEMENTS

xlv

When Prescribing

OL SantaL ^lav,

if the drug is administered in
SAVARESSE’S MEMBRANOUS
CAPSULES the patient will be
caused

No NAUSEA.

No “BEPEATING/-
No ERUCTATIONS.

Each tin contains 24 x 10 minim Capsules.
The Sandal Wood Oil in

= SAVARESSE’S CAPSULES =

being distilled by ourselves, Physicians
may rely upon its absolute purity, and
look for a definite result at a reasonably
early date.

Sample on application.

EVANS SONS LESCHER & WEBB Limited,

60, Bartholomew Close,
LONDON.

56, Hanover Street,
LIVERPOOL.

ADVERTISEMENTS

A'ivi

The Saccharin Corporation

Sole Manufacturers and Patentees of SACCHARIN
in the United Kingdom, also offering the following
Preparations to the Medical Profession.

DIAMALT

Malt Preparation of Highest
Diastatic Strength.

DAIMALT AND PARAFFIN

TRIVALIN

(OVERLACH)

New Valerian Preparation —

HARMLESS SUBSTITUTE for
MORPHIA, NERVE TONIC
and ANODYNE

Specially recommended in inoper-
able cancer, gall-stone, sciatica,
neuralgia.

Powerful tonic in delirium, mental
disturbances. Hysteria.

In ampuls {1 c.c.) for Hypodermic
Injections and Coated Tablets for
Internal Administration.

DAIMALT AND COD LIVER
, OIL

DAIMALT AND OLIVE OIL

DIAMALT AND MILK

DRY DIAMALT

A Crystallized Extract of Malt.

NOVOCAIN

TULLOCH’S

The Non-Irritant

Local Anaesthetic.

ALLOYS

GOLD MEDAL

at International Medical Congress,
London, 1913.

GOLD ALLOY

SILVER ALLOY

COPPER AMALGAM

Novocain does not contain
Cocain.

Alloy Measuring Spoon and Mercury
Measure.

Supplied to

His Majesty’s War Office

and

HIS MAJESTY’S INDIA OFFICE

Manufactured under Scientific
Supervision from published formulae
in Messrs. Tulloch Co.’s Labor-
atories, Sidcup, Kent.

Price List and JJteratnre on application ,

THE SACCHARIN CORPORATION, LTD.

10, Arthur StreeJ, LONDON, E.C.

Telegraphic Address: “ SACARINO,” EONDON. Telephone; 197 Rink,

A D VERTISEMENTS

xlvii

BAYER’S PHARMACEUTICAL PRODUCTS.

ACiTRIN

Gout Specific.

Dose, 1 tab. 4-16 times
ft day.

4 grm. (7i gr.) tabs., in
original tubes of 20.

CORYFIN

Prolonged ^Menthol
Action

Dose, 2-5 drops
or locally applied.

1 oz. bots., special bots

Coryfin Pastilles
original boxes.

FERRO-

SAJODIN

Tonic and
Alterative.

Dose, 71-15 grs.
thrice daily.

74 gr. (4 grm.) tabs, in
tubes of 20.

HYDRASTIN-
INE HCL.

Haemostatic
(uterine, &c.)
Dose ; 2/.') gr, tablet.

Powerful hypnotic
and sedative.

Pose, Luminal S-6 firs . ;
Lumin-Sod. (hypoder.)
S-S c,c. of 30 p.c. sol.
Luminal, ioz, bxs„ Ij Si
fi tiv. tabs, in tubes of 10.
Lum.-Hod., 4 oz, bots.

SAJODIN

Organic Iodide.

J>osc, 7)-ir) grs., t.i.cl.
i and 1 oz. liottlos,
tubes of 20 X 74 gr.
V, grm.) tabs.

TENOSIN

Improved Erj^ot
preparation.

Dose, 20 drox)s, t.i.d.

Original bottles of
solution.

ADALIN 1

Sedative & Hypnotic

Sedative 5-10 grs.
Hypnotic 10-15 grs.

4 1 oz. bxs. 5 gr. tabs.

ill bots. of 3S & too. Ik
gr. (4 grm.) tablets in
tubes of 20.

ARiSTOL

Odourless Antiseptic

Applied in strengths
of 5-50 per cent.

4 oz. and 1 oz. bottles.

ASPIRIN

Anti-Rheumatic
and Analgesic.

Dose, 10-15 grs. t.i.d.

1 oz. boxes; tablets.
25x5 gr., 100x5 gr.,
20X7V gr.

CYCLOFORIVI

Antiseptic and
Anaesthetic.

Applied In strengths,
5'yo~10'»/o-100Y«

1 oz. boxes.

Ung. Gycloform Co.
original tube (1/9).

CYMARIN

Cardiac Tonic and
Diuretic.

Dose : Internal, 1 tab.
('3 mg.) 2-5 times daily
p.c.

Ampullse (1 cc. sol.) in
boxes of 10. Tablets (*8
mgJ in original bottles
,of 50 (2/6).

ELARSON

Organic Arsenic
Compound*

Dose. 1-2 tabs., 3~5
times daily.

Tabs (== i mg. As.) in
original bots. of 60,

GUYCOSE

Used in all respira-
disorders.

Dose, 1-2 teaspoon-
fuls, t.i.d.

Original bottles
dispensed at 2/9 each
(Coutents sterilised.)

HELMITOL

Urinary Antiseptic.
Dose, 15 grs. dissolved
3 or 4 times daily.

1 oz. bots., 2.5 and 100

5 gr. tablets.

Tab. Helmitol Co.
(c. Ac. Sod. Phos.), in
tubes of 20.

HEROIN HY-
DROOHLOR.

Improved Morphia
Product.

Dose, 1/240-1/8 gr.
Tubes of 16 grs., i
i- oz. bottles, 25 X 1/24
gr. tablets.

IROCOSE

Iron Tonic.

Dose, 1-2 teasp. t.l.d.

Original Bottles,
dispensed at 2/9 each.
(Contents sterilised.)

ISTIN

Purgative.

Dose, 1-2 tab. before
bedtime.

5 gr. tabs, in original
tubes of 30 (1/6).

JOTHION

External Iodine
Preparation.

Dose, 5-10-25

1 oz. bottles;

Un^. Jothion (Bayer)
original tube 1/1.

PHOSPHO-

COSE

Nerve Tonic.

Dose, 1-2 teasp. t.i.d.

Original bottles,
dispensed at 2/9.
(Contents sterilised.)

POLYLAOTOL

Galactagogue and
Tonic.

1 teasn. 2-4 times
daily.

Original bottles (2/9)

PROTARGOL

Organic Silver

Compound (8'3V> Ag)
Dose, 1/4-20 per cent.

i and 1 oz. bottles ;

' 25 X 4 gr. tablets.

SOIVIATOSE

Heat Albumose.

Dose, 4-1 teasp., t.i.d.
'J'ins of I, 2, 4, & 8 oz.

Liquid Somatose.
Original bottles,
(2/0) sterilized.

SPIROSAL

External

Anti-Rheumatic.

Dose, 4 teasp. applied
t.i.cl,

1 oz. bots.;
Spiro-salin (Spirosal
l pt., a. Y. R. 2 pts.)

TANNIGEN

Intestinal

Astringent.

Doso, 5-15 grs. cpo.s.

1 oz. bottles; 71 gr.

(A grm). tablets in
tubes of 10.

THEOCIN-
SOD. ACET-

Powerful Diuretic.
Dose, 14-4 grs., t.i.d.,
p.c.

i & 1 oz. bots ; Tubes
20 xD gr., and bots.
25 X 4 gr . tab - . (Theo-
cinoids).

THYRESOL

Improved Sandal-
wood Preparation.

Dose, 5-10 min. t.i.d.
Capsules (5 min.) in
boxes of 30

VERONAL

Hypnotic.

YBRONAL-SODIUM
Soluble Hypnotic.

Dose, 5-15 grs.

1 oz. boxes ; 10 x 7| gr.
25 and 100 X 5 gr.
tablets.

Other products include Afridol Soap, Alypin, Asurol, Citarin, Coryfin, Euquinine,
Gynoval, lodothyrine, Iron-Somatose, Sfesotan, Novaspirin, Phenacetine-Bayer,
Sabromin, Salophen, Sophol, Suiphonal-Bayer, and Trional-Bayer.

THE BAYER CO. LTD.,'“ "

xlviii

ADVERTISEMENTS

“VASELINE”

AND

REUABIUTY

U NDER aJJ conditions, in all climates, and in a
multitude of uses, “ Vaseline ” remains uniform,
consistent, reliable and safe. c. The Medical
Profession knows more than anyone the dangers of
substitutes, masquerading , under names, and often
under guises intended to deceive the unwary,
c Numerous cases have been ruined by the calling
into use of substances foisted upon the unthinking
or unknowing person sent for “ Vaseline.” It cannot
therefore, be too strongly urged that the doctor instruct
those who visit the chemist’s, to insist upon Vaseline,”
the genuine product of the Chesebrough Mfg. Co., and
upon seeing the name on the label. c. Known
and trusted throughout forty-two years,
Vaseline” has spurx'ed into being,
many undesirable imitations, of
the existence of which the
average member of
the public does
not even
guess.

The word “Vaseline” is the % Registered
Trade Mark of the

Chesebrough Mfg. Co. (Cons’d.)

42 Holborn Viaduct
London E.C,

Complete price list of all the “Vaseline” preparations
will be sent post free .on application.

ADVERTISEMENTS

xlix

8, HARP LANE, LONDON, E.C.

ANTHRASOL.

A purified colourless tar, freed
from pitch. Applied in skin
diseases, especially in itching.

ARSEN-TRIFERRIN.

An organic arseno-iron prepar-
ation. Dose : 5 grains three
times a day, in tablets or powder.

BROMURAL.

A powerful sedative and mild
hypnotic, with out narcotic action.
Dose : as a sedative, 5 grains
several times a day, as a
hypnotic, 10 grains at bed-time.
In tablets or powder.

CODEONAL.

A combination of diethylbarbi-
turate of soda, and diethyl-
barbiturate of codeine. The
hypnotic action of the former is
reinforced by the addition of a
small quantity of the latter.
Dose : two tablets before bed-
time.

DIGIPURATUM.

Physiologically standardised
preparation of the digitannoids,
uniform in action and stable in
composition. In powder, tablets,
ampoules and solution for oral
administration.

DIURETIN.

A typical diuretic, heart tonic
and vaso- dilator. In tablets and
powder.

EUGALLOL.

A vigorous agent in inveterate
and obstinate cases of psoriasis
and lupus vulgaris. Applied
as a paint.

EURESOL.

A liquid resorcin preparation,
indicated in acne vulgaris,
eczema, frost bites.

EURESOL PRO CAPILLIS.

Euresol plain, with the addition of
a fine perfume, for Hair Washes.
Indicated in seborrhoea, and loss
of hair, etc.

LENIGALLOL.

Pyrogallol preparation. A typi-
cal remedy for eczema. Has no
action on healthy skin. Applied
as a 3-5 per cent, paste.

SANTYL.

An absolutely non-irritant balsam !
for the internal treatment of gon » '
orrhoea. Free from unpleasant
taste and smell. No eructations.
Administered in the form of
drops or capsules.

STYPTOL.

A reliable uterine heemostatic, '
Without undesired by-effects.
Acts as an antiphlogistic and
sedative. Dose : 2-3 tablets
three times a day.

STYRACOL,

An effective guaiacol prepara-
tion indicated in diseases of the
respiratory organs, as well as an
intestinal disinfectant and anti-
phthisic. Pleasant taste. Dose:
15 grains, three to four times a
day. In tablets or powder,

TANNALBIN.

A non-irritant intestinal astrin-
gent. Its action extends as far as
to the lower portion of the large
intestine. Dose : 15 grains three
to five times a day. In tablets
or powder.

I ADVERTISEMENTS

APERITOL

Contains the purgative phenolphthalein combined with the
sedative principle of valerian. A mild and absolutely
harmless laxative, in form of pleasant tasting bonbons and
tablets.

NEO-BORNYVAL

Besides our well known BORNYVAL we introduced
into the Materia Medica this almost tasteless and odourless
sedative and analeptic which is readily taken even by the
most sensitive patient and is not liable to cause eructations.
Obtainable in form of gelatine pearls.

SALIPYRET

Is a chemical combination of antipyrine and salicylic acid.

It is indicated in cases of influenza and colds generally,
neuralgia, headache, acute and chronic rheumatism and is
obtainable in tablet and powder form.

SCOPOMORPHINE

Is much in use in several large hospitals. It is indicated
, in complete anaesthesia, semi-anaesthesia for labour, etc., and
as an analgesic and sedative. The 1 c. c. ampulla contains :

Scopolamine Hydrobromide “Riedel’* 1/1 00 grain

Morphine Hydrochloride ...

Aqua destillaia . . . . . ad 1 c.c.

the 2 c.c. ampulla contains double the quantities.

Articles about our preparations will be found iti “Riedel s
Record” which Journal we are sending, free of charge, to
Medical Practitioners who apply for same.

Wj.d.riedelc?.

l3/l4.WALBROOK.LOMDOrf.E.c: -

BERLIM-MlLAfi -NEWVORKrST PETERSBURG

ADVERTISEMENTS

GONOSAN

Isa combination of 20 % Resin of Kava Kava and 80 %
guaranteed pure East Indian sandalwood oiL The great claim
for Gonosan from a pharmacological point of view is that it
does not irritate the stomach and kidneys. Put up in form of
gelatine capsules.

HEXALET

Is a chemical combination of sulpho -salicylic acid and
hexamethylentetramine. It represents a most reliable
sedative urinary antiseptic, Hexalet is indicated in acute
and chronic inflammations of the bladder ; posterior
gonorrhoea in order to prevent infection of the bladder ;
bacterial diseases of the urinary tract, i. e. pyelitis and pyelo-
nephritis ; uric acid diathesis and uric acid deposits in the
kidneys and bladder. Put up in tablet and powder form.

MERGAL

An organic mercurial salt for the internal treatment of
syphilis. Each capsule contains f grain of mercury cholate
and 1 1 grains of tanalbin, A well known London Derma-
tologist writes : “I have found Mergal of material benefit
in syphilis, soon changing a positive into a negative Wasser-
mann*s reaction. ” Put up in form of gelatine capsules.

THIOL

Is a non-irritant and odourless sulphur preparation. It is
indicated in skin diseases, diseases in women, rheumatism,
gout, nose and throat affections, burns, etc. Thiol is ob-
tainable in dry form (Thiolum SiccumJ and in liquid form
(Thiolum Liquidum).

For full descriptive literature apply to

TKeJ.D.RIEDELC?

l3/l4.WAtBR0OK.LOrj D ON. e .c .

BERLm-MILAFi -tSEW VORK-ST PETERSBURG

A OVERT IS FOMENTS

tro *lbfs /ifcajeatfi BbwarD vii.

BRAND’S

SPECIALTIES
FOR INVALIDS.

Manufactured from the Finest BRITISH MEATS.

ESSENCE OF BEEF

AND OF

.CHICKEN AND MUTTON..

Valuable in cases of exhaustion, depression, and weak digestion due to influenza
or any other cause, being easily assimilated by the weakest stomach, imparting
at once fresh life and vigour to the whole system.

These Essences are now put up IN GLASS.

Invalid Jellies and Broths.

Mutton, Chicken and Beef Tea Jellies.

These preparations may be taken either as jellies, or made into appetising
nutritious drinks by putting a wineglassful into a breakfast cup and filling up
with boiling water.

Savoury Meat Lozenges,

FOR . .

**A meal in your waistcoat
pocket , "

INVALIDS, SPORTSMEN.
ATHLETES, &c.

Full price lists on application to

. BRAND & CO., LTD. .

Mayfair Works, Vauxhall, LONDON, S.W.

ADVERTISEMENTS

liii

EVIAN-CACHAT WATER

(Famous since the 18th Century)

is strongly recommended by the highest medical authorities of
France, Germany, and England because it is :

1. Free from both natural and artificial

carbonic gas,

2. The most aseptic water known,

3. The most effectively diuretic, and

4. The one easiest absorbed and most

rapidly eliminated.

The bottling process of this water, fully described by The
limes, represents the maximum perfection attainable.

Essentially the table water of the aristocracys the
one most consumed at the Ritz, Savoy, and Carlton Restaur-
ants ; the annual sale, nevertheless, exceeds 13,000,000 bottles.

EVIAN-LES-BAINS,

probably the most beneficial of all watering places. For the
treatment of chronic gout, dyspepsia, neurasthenia,
arterial hypertension, gall-stones, renal calculus,
and all kindred ailments its reputation is world-renowned.

The Etablissement for all kinds of hydrotherapic
treatment, massage and electricity, ranks among the
first in Europe.

The town of Evian boasts of offering its visitors the most
comfortable and perfect accommodation in France. The
^‘Royale” and‘‘Splendide'’ Hotels are under the manage-
ment of the Carlton-Ritz Hotels of London.

Casino, Theatre, Golf Links, Lawn Tennis, Regattas,
Motor Boats, etc. Mildly bracing climate. Beautiful Views.
Daily Train de Luxe from Paris. Distance from London 1 8 hrs.

SAMPLE CASES of EVIAN-CACHAT WATER will be sent gratis and carriage paid
to Members of the Medical Profession on application to —

THE EVIAN-CACHAT AGENCY,

Or to the Wholesale Affents—

Messrs. 1190BAM & BOYLE, Ltd., at London, LiverpooL and Bristol.

Sold by all the Principal Chemists, Druggists, Stores, etc.,
in Great Britain and throughout the World.

ADViCRTISKMHNTS

ROTUNDA LYING-iN HOSPITAL

DUBLIN.

Master: HENRY JELLBTT. M.D.. F.R.C.P.I.

I.Htc King’s Professor of Midwifery, iHililin Univeisiiy.

Assistants to the Master: D. Q. MADILL, M.Dm R. MARSHALL ALLAN, M,D.
Pathologist: R. J. ROVVLETTE, M.l).

Accommodation is provided fona Xiimited number of Intern Fnpils.

PITPIXiS CAN ENTER AT ANY TIME.

There are over 4400 deliveries in the year, and the work performed by
it is about three times greater than that of any other
Hospital of its kind in Ireland.

The I online daily work comprises the attendance of Lectures on Midwifery and Cl yn; ecology ;
practice in abdominal jialpation ; personal conduciion of paiturition both in the KMcrn and Intern
iMatcniities; cysto.scopic examinations; and attendance at and assistance in the opt*rati\e work
of llie Hospital.

’I'he Hospital affouls evccptional advantages Uf (lualified men wlio take out .'i two months’
conise, for they (if considered competent) are i)ermitted a ccituin anionnt of practical operation
work, viz.: forceps, enrettings, pennieorrhnphics. etc.

'riic Pathological Lfd)oratory is also available foi the use of Sludcnls wiihoiil cMivi ftx‘.

'J'lie liesidential quarters — noth for men and tvomen — have been re-organised, rebiuli, and
refurnished, and many improvements have been made, such as electric liglit new plnmliing tlirougla)iit,
new kitchen, new reading-room, many separate bedrooms (no l»eilrooni in ilie residency now holds
more than two stndetus), now hilliiud table, etc. 'J‘he management of the La<ly Students quarters has
been transferred to the “ Students’ Housekeeper,” and a new tliuing-room has heen provided, the
former dining-room being used as a sitting-room only. I'hree new guiss teniiis eomts h.ivr been laid.

Women are trained as Nurse-tenders and Midwivos.

Fee, including Board and Eodging for six months, 26 Guineas.

For further particulars apply to The Master, Rotunda Hospital, Dublin,

LONDON ;

43, NHW CAVENDISH ST„ W.

MANCHESTER :

170, OXFORD ROAD.

GLASGOW:

28, WINDSOR TERRACE,

DUBLIN;

47, MESFIL ROAD.

TBLEPHOTIES :
London :

1277 Wayfair.
Manchester;

3213 Central.
Glasgow ;

477 Central. .
Dublin :

331 Ballsbridge.

MALE NURSES

TELEGRAMS:

” TAcniiit,

y.n.V/aj.V.'*

“ TAcn:j.i{,
MA^CllKSTKil,'
‘Ls' f; 'AL,

iihAHtHiWA'

*'TA(rrr<:An.

JA'ltJ.ISA*

Superior trained Male Nurses
for Medical, Surgical, Mental,
Dipsoniiania, Travelling and all
cases. Nurses reside on the
premises, and are always ready
for urgent calls, day or night.
Skilled Masseurs and good
Valet Attendants supplied.

CO-OPERATION.

The Nurses are fully insured

against accident.

Terms from £1 16s. 6d.

M. D. GOLD, Secreta/y.

AbVJiRTlsniMEN'tS

Royal School Indigent Blind

LEATHBRHEAD, SURREY,

FouriDED nr southwhrk, 1799.

mCORPORFlTED BY ROYHL CHARTER, 1826.

REBUILT FLT LEnTflERMEHD, 1902.

x-7 e e-1314.

IIS years of national
work with the Blind
of the United
Kingdom,

^ Contributions
earnestly pleaded
for.

The Rev. ST. CLARE HILL, M.A.

Principal and Secretary t

Chief Offices :

HIGHLANDS ROAD, LEATHERHEAD.

Telephone No. 4, P.O. Le.atherhe.ad.
Telegraphic Address: "Lux, Leatherhead."

THETFORD PULP WARE.

(AfADB IN ENGLAND,)

Special Features : UNBREAKABLE, LIGHT, ARTISTIC, and DURABLE.

LEWIS’ SANITARY

CHAMBERINE COVER.

^^0 0^ Finished in White or Cream.

Inches diameter S 10 '

Each 1/- 1/3 1/6 post free.

The Hospiiai writes: “Especially to be recommended are the excellent little Covers
for bedroom lUen.sil.s, of whiclt mention has been made before in the ‘Hospital.’ They are
eniineiuly .sanitary and non -absorbent, and everyhou.se should possess a supply.”

OVAL “UNBREAKABLE” TUBS.

LIGHT, STRONG, DURABLE.

No hoops to drop or rust off.
Enamelled White inside, Brown outside.

No. 1. — 17 X 33^} X 5J inches ... each 2/6
,, 2.— 19 X 16 X 6 ,,3/6

If sent per Parcel Post, add Sd. extra.

May be obtained through the Principal Stores, or if any difficulty, write to DEPT. M.A.

The PATENT PULP MANUFACTURING CO. Ltd. n.

Works: THETFORD, NORFOLK. Established 1879.

ADVlSRTlSEMEKTS

ADVERTISEMENTS

POPULAR HOTELS IN
CENTRAL LONDON.

OPPOSITE THE BRITISH MUSEUM.

THACKERAY Hotel

Great Russell Street,

z^^LONDON.

NEAR THE BRITISH MUSEUM.

KINGSLEY HOTEL

Hart Street, Bloomsbury Square,

z^^^LONDON.

^^HESE well-appointed and commodious TEMPERANCE
^ HOTELS will, it is. believed, meet all the requirements,
at moderate charges, of those who desire all the advantages
of the larger modern licensed hotels.

THESE HOTELS HAVE

PASSENGER LIFTS,

BATH ROOMS ON EVERY FLOOR,
LOUNGES and SPACIOUS DINING,
DRAWING, WRITING, READING,
BILLIARD, and SMOKING ROOMS.

Perfect Sanitation. Fireproof Floors. Telephones. Night Porters.

Bedroom Attendance and Table d'Hote

Full Tariff and

Breakfast, Single, from 5/6 to 7/6

Testimonials . .

With Table d^Hoie Dinner, from 816

ON Application.

TBLBORAPHIC ADDRBSSBS :

Thackeray Hotel — I Kingsley Hotc'--

“THACKERAY', WESTCENT, LONDON.” I “ BOOKCRAFT, WESTCENT, LONDON,”
TBLBPHONBS : Regent 2041 (2 lines); Regent 2083 (2 lines).

Iviii ADVKHTlSEMErN’TS

Swedish Training School for
Massage and Remedial Exercises.

16 YORK PLACE, BAKER STREET, W.

Principal: Mrs. WILSON, Tnsimctress of Medical Gymnastics and' Massage at St. Bartholomew's
Hospital; Holder of Government Uiiyloma of Geimany ; trained in Sweden; aided ■
hy a Staff of Teachers trained at Dr. Arveilsoyi's School, iitocleholvi.

One year’s course, which is strongly recommended, and on which a reduction is made,
prepares unpils for the two examinuLions of the Incorporated Society of Trained Masseuses,
viz., tho Massase and the Swedish Bemedial Exercises Examinations. It includes Anatomy with
l:)is>ections, Physiology, Theory and Practice of Swedish Massage and Medical Gymnastics,
Bandaging, Lectures on Diseases (Medical and Surgical). J'llectricity, including Galvanic
and Fai’adic Baths, High Frequency, Radiant Heat, and Nauheim Bachs, also the teaching of
lihysical Exercises to Classes of School Children.

«' Trained nurses can be prepared for the I.S.T.M. Massage Examination in six months, who
at the same rime, receive six months training in Elementary Swedish Medical Gymnastics,
Students who hold the I.S.T.M. Massage Certificate can be prepared for the S.R.E. Examination
in six raontlis.

The nurses of St. Bartholomew’s Hospital are' trained for Massage at Mrs. Wilson’s School.
Clinical Work is a great feature of the Scool. All students treat Spinal Curvature, Deformities,'
Fractures, and General Massage Cases' at Hospital under Mrs. Wilson’s supervision. The School
lias a high record for iiasses at the above examinations. A second year’s course in iweparation
for the I.S.T.M. TeiKjher's Diploma has been arranged to train candidates in the theory and
practice of teaching Medical Gymnastics Massage, and Anatomy."

The Peile-Seyfang Foot-Rest

Patkki’ 3072 of 1012

The Peile-Seyfung Foot-llcst enabIcK small (duldren to
sit comfortably at table on an orUinafy chair, as itpn»vidc.s
a sufrtclent support for the feet.

it. is small in bulk, light in weight, and easily adjusted
to any chair.

Sitting with the feet “ dangling” is oft«*n vesjxmRible for
unnecessary fatigue in childhood, curvature of the spine,
impaired circulation (swollen and painful feet in summer—
cliin)lains in winter), defective dlgeHtion, etc.

Will bo shown at the Children’s Welfare Exhibition at
Olympia, and also at the Nursing Exhibition atthuHorti-
eulturul Hall in April n(‘Xt.

Can he ohlained from, and is o7i rirw at

The Peile-Seyfang School of Health Exercises

36, Dorset Square, LONDON, N.W.

Telephone : Paddington 6179 . PRICE 3/6 EACH, POST FREE.

The Peile-Seyfang School of Health Exercises, (without Apparatus)
FOR WOMEN AND CHILDREN.

Highly recommended by the Medical Profession for all cases of Muscubu' VVeaknesr,
and by Teachers of Hinging, for the development of the Lungs, and for the strengthening
of the Muscles of the 2’hroat, Tongue and Lips.

contntunkaiions to be addressed to : —

miss LILIAN PEILE or MISS ELLA C. SEYFANG, ,

Telephone ; 6179 Paddington* 86 , Dorset Square, LONDON, N.W.

A D V K RTIS1?MENTS

lix

MARTINDALE’S PR/ESCRIPTA

(Gold Medal, International Congrress, 1913

“ Tylcalsin ” and “ Tyllithin ”

Trade Marks; Patent),

In treatment of Influenza, Catarrhs, Neural-
gias, Rheumatic Affections, Sciatica, ami
wherever prompt Analgesic effect is required.

I oz. 2/- ; 8 oz. package 15/8 ; i6 oz. 30/8
Tylcalsin Tablets .. 36 2/6

Tyllithin Tablets - . 20 1/6

7 '/ie British Medical Journal (14th June,
1913, p. 1277), says: — “Tylcalsin and Tylli-
thiti are very readily soluble in water, and
their solutions rapidly undergo hydrolysis in
the presence of alkali, showing salicylate in ,
considerable quantity after a very short time.
The advantage presented by these salts over
acetyl -salicylic acid is, of course, their far
greater solubility, favouring rapidity of
action.

Elixir and

Emulsion of Lecithin

Palatable preparations of the
nerve nutrient Lecithin.

1iik~

and Glycerophosphate

A useful combination containing
all the natural solids of Fresh
Milk (including all its cream) and
Calcium Gl^^cerophospbate. As
a Nerve nutrient.

Bottles 2/- each.

AMYL NITRITE CAPSULES

IN COTT'ON WOOL AND SILK,
containing i, 2, 3, 4, 5, 6, or 10 minims {<ro^, 0*1. 0*2,
0-25, 0*3, 0*35, or 0-6 c,c._ approx,), the usual dose being

FOR RELIEYING ANGINA PECTORIS. AGUE,
SPASMODIC ASTHMA, MIGRAINE. POST PAR-
TUM HJEMORRHAGE, HEMOPTYSIS, SEA-
SICKNESS, TO WARD OFF EPILEPTIC ATTACKS,

&c., AND AS AN ANTIDOTE TO CHLOROFORM.

Largely employed in threatened Fainting and Collapse, and as a restorative after Gas,
in Dental Operations.

Full lists on application.

W Mjl H |MaMi| ■■ li ■ p MANUFACTURING CHEMIST,

. MARTlNuALC, 10 new cavendish ST., LONDON, W.

Telegrams: Martindale, Chemist, London***

AD VE RT IS ETvI E NT S

fUm
HOUSE

Winter

health Resort
at the foot
of the

Great Pyratriids.

JO viinut^s from
Cai>o ly tra.ni.

DESERT AIR CURB; COUNTRY LIFE.

This comfortable Hotel is becoming more and
moie popular with many distinguished families,
most of its English patrons staying here through-
out the Winter, from November until May.

Golf, Tennis, Croquet, Races. Arab Riding
Horses Sl Sandcarts on Hire. Concerts.
Own Uaiiy. Best water in Egypt. Motor Bus
service from Cairo, Swimming Bath.

Pension Terms ■from 13/- to 20/-

English Chaplain, Res. P/iys. : Dr. Savage.

'?rr;HELOUAN
BATHS

The famous
Watering^ Place
and KealtI]
Resort in the
Desert,

20, viimites mil
from Cairo.

The only place where during winter marvel-
lous cures can be effected under ideal climatic
conditions, in cases of :

Gout, Rheumatism, Sciatica, Lumbago,
Kidney Troubles, &c. English Physician,
Golf, Tennis; Casino, Concerts, See*
Medical Diicctor: Dr. Ov^erton Hobson’,

CRAIMD HOTEL., HEtOUAN.

First Class, with every modern comfort.

Terms: 13/- to 20/-
HOTEL DES BAINS.

Comfortable Family Hotel, opposite Rath
E.siabli.shment. Terms: 9/- to 13/-

Kor illusiratcd firospectus apply :

A. WILD BEY, General Manager, Continental Hotel, Cairo; or
FOREIGN RESORTS BUREAU, 1, Southampton Row, London, W.C.

MADEIRA (Funchal)

REID’S HOTELS.

Appointment to tbc IDuhe of iEbinlnu\ib.

EstabUshod 1850. 34 days frem England.

7 days from New York.

Winter Average 61 ° F.

Complete Freedom from Dust.

REID’S PALACE HOTEL

(Luitu NfW IlnUd) luul AuiioxcH.
ISwlHH JM/tmigur,

HU-uaU'd nn llm CIUTh to the West of
Fundml, Mtamllng iii the largest, hotel
gardens in Manetni} nverlnoUlng tlw!
Sea, grand view ef the IVInmitalus. I*!!!,.
Sun. Bathing and Boating. Bcnihinu IDs.
to 'das. daily.

REID’S CARMO HOTEL

In sheltered central tiOHltimi, large
gardens. PeiiHioii 8s. Gtl. to 18/-, dally.

These FIRST -CLABH HOTELS, all
lighted by electricity, afford every com-
fort for families and travel leva. French
and English Cuisine of highest class,
and Choice Wines, 'L'ennis Conns, large
Gardens, Baths, Eeailing and Sinol£ij)--g
Booms, JOnglish, French and Goi nutn
Newsuapers. Billiards. 'J'hc SANFl’AHV
arrangements are hv the Banner Sanita-
tion Co., London. Water direct from a
private mountain spring, 3000 feet iiljove
sea-level. All Steamers met.

REID'S MOUNT PARK HOTEL

Monte 2000 feet ahevc* sea-level.
Tension 7 h. (id. to iOs. dfuly.

TeUdnms : “Reid, Funchal,” A.B.C., Lieber’s and Unicode. Pamphlet of The Madeira
Agency, 1 Adam St., W.C.; Hotel Tariff Bureau, 275 Regent St., London; Thos. Cook & Son,
Ludgate Circus, &c., the Steamship Companies; or ViT. .ind A. Reid, Madeira.

Fcllows^Sympus

Hypophosphitum

Quadraginta per annos et a medicis et ab
aegris orbis terrarum totius probatus

Compositio sui generis neque imitabilis

^ ^ Cheap and Inefficient Substitutes

^ Preparations ‘‘Just as Good"

HELOUAN, EGYPT.

The famous Watering Place & Health Resort in the Desert.

The only place where during the winter cures
can be effected under ideal climatic conditions.

RENOWNED BATHING ESTABLISHMENT. SULPHUR SALINE WATERS.

Completely reinstalled 1912,

The Waters and the Climate of Helouaii are especially useful in the
following disorders ; —

lllieumaii'^m in all il,s forms, Phi'umatoid Arthritis, Neuritis, Gout, Stiff Joints, Lumbago, Sciatica,
Chronic Skin Ihsease, Functioniil Nerve Disorders, r5ri«hfs Diseaso and all forms of Albuminuria
luseases of the Uospiratory Orf4uns and CH»ieciolly Asthma. KNtVLlSH PHYSICIAN,

Best Golf Links in Egypt (English Professional). Tennis. Concerts.

?lu'4lish Chnrch with Resident Eii-jlish Chaplain.

GRAND HOTEL. HELOUAN.

The best Hotel in Helouan. Strictly First-class. Home comforts.

^ Lift. Renowned cuisine.

SUITES OF APARTMENTS WITH PRIVATE BATH cO TOILET

PENSION TERMS-13/- to 20/- per day.

Hotel Pension des Bains,

PENSION TERMS-9/- to 12/- per day.

For information and pamphlets, apply A. PETRY, Manager,

Bath Establishment, Helouan, Egypt.

ADVERTISEMENTS

Lxii

BUTTERWORTH & CO.

(AUSTRALIA) LTD.

IMeclicail Publishers.

50LE AGENTS for the Medical Publications of D. APPLETON & CO.

A large and comprehensive stock of new and recent medical works
always in hand — write for a copy of the most complete medical catalogue
yet produced, containing particulars of over 3,000 Books, which will be
sent post free on request.

ASK FOR PARTICULARS
OF INSTALMENT SYSTEM.

FORCHHEIMER’S THERAPEUSIS OF INTER-
NAL DISEASES.

4 vols., and Desk Index. Price £5 5s. net per set

OSLER’S PRACTICE OF MEDICINE. Eighth Edition.

Price 21s. net

SAJOUS’ ANALYTIC CYCLOPAEDIA OF MEDICINE
AND SURGERY. 8 vols. Price 29s. net per vol,

SAVILL’S CLINICAL MEDICINE. Third Edition.

Price 29s. net

GUITERAS’ UROLOGY. 2 vols. Price £2 10s. net per set

SAJOUS’ INTERNAL SECRETIONS. I-ifth Edition.

2 vols. Price £2 10s. net pcj' s(‘t

ROSENAU’S PREVENTIVE MEDICINE & HYGIENE.

Price 2Ss. net

WILLIAMS’ OBSTETRICS, a'hird Edition. Price 25s. net

HOLT’S DISEASES OF INFANCY & CHILDHOOD.

Sixth Edition. Price 25s. net
FOOTE’S MINOR SURGERY. Third Edition.

Price 21s. net

JUST PUBLISHED.

LOXTON’S MEDICAL DIRECTORY OF AUSTRALIA,
NEW ZEALAND, TASMANIA, etc., for 1914. -

Price 15s. net

Sir'Uii for Nctv Illush'ated Catalogue.

BUnERWORTH & GO. "

(AUSTRALIA) LTD.

London Office: 4, BBLL YARD, W.C.

ADVERTISEMENTS

Ixiii

BUniRWORTH & CO.

(INDIA) LTD.

Medica.! Publisl&ers.

SOLE AGENTS in India, for the Medical Publications of

D. APPLETON & CO. J, B. LIPPINCOTT COMPANY
J. BALE, SONS 8 l DANIELSSON.

Write for particulars of SPECIAL Largest Stock of English and American
MONTHLY INSTALMENT PLAN. Medical Books in India always in hand.
Send your name for registration, stating Any Works not in Stock cabled for
which subjects you arc specially inter- free of charge,

ested in, to receive advice of new books,-**

A feiv Books from Biitierworths" List :

LATHAM & ENGLISH’S SYSTEM OF TREATMENT.

4 vols. Price Rs. 68 net per set

SAJOUS’ ANALYTIC CYCLOPiEDIA OF MEDICINE
AND SURGERY. 8 vols. Price Rs. 21.12 net per vol.

(over 40,000 SETS SOLD TO DATE).

FORCHHEIMER’S THERAPEUSIS OF INTERNAL
DISEASES. 4 vols. and Desk Index.

Price Rs. 78.12 net per set

THE TUBERCULOSIS YEAR BOOK & SANATORIA
ANNUAL, 1913-14. Price Rs. 5.10 net

DANIELS’ TROPICAL MEDICINE. Part I . Second
Edition.* Price Rs. 5-10 net

FUCHS’ OPHTHALMOLOGY. Fourth English Edition.

Price Rs. 18*12 net

OSLER’S PRACTICE OF MEDICINE. Eighth Edition.

Price Rs. 15.12 net

Butterworth & Co. (India) Ltd., are special agents for thie folloiYing periodicals :
BRITISH JOURNAL OF SURGERY. , Price Rs. 19.14 net per annum, post free

INTERNATIONAL CLINICS. Price Rs. 29.4 net per annum, po.st free

JOURNAL OF TROPICAL MEDICINE & HYGIENE. Price Rs. 13.8 net per annum, post free
THE LANCET. Price Rs. 18,12 net per annum, post free

UNIVERSAL MEDICAL RECORD. Price Rs. 18.12 net per annum, post free

Send for New Illustrated Catalogue,

BUnERWORTH & CO. ‘

(INDIA) LTD.

London Office: 4, BBLL YARD, VT.C. P.O. Box 251.

ADVERTISEMENTS

REMEMBER

MEANS

THERAPEUTIC EFFICIEWCY

ANTIPHLOGISTINE is indicated wherever a
hot compress might be used, or a poultice; in
fact, wherever inflammation or congestion is
present. Applied thick and hot, Antiphlogistine
aflbrds immediate relief in

PNEUMONIA

TONSILLITIS

PLEURISY

SYNOVITIS

LARYNGITIS

BRONCHITIS

QUINSY

BOILS

LEG ULCERS.

ANTIPHLOGISTINE should be heated by
j;)lacing the tin in hot water, taking care th.at
no water gets into tlie preparation. Spread it
over the affected part at least I inch thick, and
cover with cotton wool and a retaining bandage.
When applied over the lungs, a light body
binder, with holes for the anus, may be used
over the cotton wool.

THE DEHVER CHEMICAL MANUFACTURING GO.

BOW. LONDON.

New YORK SYDNEY PARIS BERLIN

Selling Agents for India and the Orient : —

MULLER, MACLEAN & CO., 53 Meadow Street Fort, BOMBAY.

ADVERTISEME NTS

DOMEN BELTS

System II BELT.

Price 17/9

The most efficient Belt for wear
after various abdominal
operations, etc-

DOMEN PATENT
BANDAGING.

Elastic (without
rubber), porous, com-
bines great strength
with light weight:
Send for a free sample
Bandage.

“STOWAWAY*
SUSPENSORY.
Perfect Fittingr.

1st quality, Cotton

2/3

2nd quality, Cotton

1/6

1st quality, Wool

4/6

Design No. 50 A.

Price ... 9/6

A useful Belt for General
Support.

Write for fully Illustrated List {No* 17D) to

DOMEN BELTS Co. m

456, STRAND (Charing Cross),

LONDON, W.C.

Ixvi

TEXTUR>£ AHTiGLU/E. 1— AKKADIAN

TRADE

Ernutin’

BRAND

Products

Present the essentials of Ergot.

(Ergotoxine, ‘Tyramine’ and ‘Ergamine’)

Unvarying in strength ; rapid and
powerful in action.

Promote uterine contraction.

Arrest post-partum haemorrhage.

^f/APOffOLE ' Brand * Ernutin/ sterile, for intramuscular
injection, in fiernie icalty-sealed containers, min. 70
and O' 6 C.O., in boxes of 6, 8/0 per box.

*£rnut/N’ (Oral), in bottles of 1 fl. oz. and 30 c.c., 210;

4 fi, oz^, 6% and 16 fl. oz., 2010 per bottle.

Obtainable of all Chemists

Burroughs Wellcome & Co., London

At the dawn of history, Sumerians and Semites were fighting
for the soil of Mesopotamia. The Semites congregated in
Northern Babylonia, and became the Akkadians of the historic
period. Here is represented the earliest
known example of Sumerian Sculpture,
probably dating earlier than 8000 B.C.
The ancient Sumerians, in attempting to
depict their deities, gave them, m some
instances, of which this is one, the like-
ness of the Semitic inhabitants whom
they had conquered. The pattern at the
base of the head-dress has been extended
as a border design.

Ixvii

TEXTUR/€ ANTIQU;€ ^ — AKKADfAN

'.■..“.■‘WELLCOME’ —
Concentrated
Diphtheria
Antitoxin

Prepared according to the latest scientific method at
the Wellcome Physiological Research Laboratories

The antitoxic globulins separated
from Diphtheria Antitoxic Serum.

1000 Ehrlich units in 1 c.c. of fluid
instead of 2'S c.c.

Supplied in hermetically ~ sealed phials as follows : —
1000 units, 2 ( 0 ; 2000 units, 3 ! 6 ; 3000 units, 5 f 0 ;

4000 units, 610 ; 5000 units, 7 0 ; 6000 units, S/O;

8000 units, 10 / 0 . Distributing Agents : —

Burroughs WELLCOiviE & Co., London

New York Montreal Sydney Capetown Milan

Shanghai Buenos Aires Bombay

London Exhibition Room: 54. Wicmore Street, W.

Jxviii

One of the most important of Modern Therapeutic Agents

= ‘VAP0R0LE’“»”

I NFUNDIN’

(Trade Mark)

[Pituitary {Infundibular) Extract]

Powerful restorative in surgical shock
or collapse.

Active uterine stimulant in protracted
labour.

Prompt controller of post-partum and
other uterine hsemorrhages.

Clinical reports confirm its reliability.

* DaporoJe ’ ‘ hif undin ’ is issued in hermetically-sealed

containers of two strengths: 0‘5 c.e. at 2! 4, and 1 c.e.
at 4l0, per box of 6 containers.

Burroughs Wellcome & Co., London

New York Montreal Sydney Cape Town
Milan Shanghai Buenos Aires Bombay
JLondon Ejchibiiion Room: 54. Wigmore street, w.

Portion of a stele of victory of a King
of Akkad, circa 2650 B.C., sculptured in
relief with battle scenes.

The fringe upon the plain martial tunic
of the central figure has been extended
and reproduced as a border.

‘WELLCOME’-

Tuberculins

Mac/e in England

At the Wellcome Physiological Research Laboratories

Fresh sterile dilutions

of the Exotoxic and Endotoxic
Tuberculins.

In 1 c.c. hermetically-sealed phials

Save time and trouble.

Make for success in treatment.

ANY STRENGTH involving only one significant
figure can be supplied, for example, 0*0006 c.c. or
0*0007 c.c., but not 0*00065 c.c., etc.

Orders immediately despatched

For full particulars, address the distributing agents:-

Burroughs WELLComE & Co.
Snow Hill Buildings, London, E.C.

From the stele of a King of Akkad, circa
2600 B.C, The texture of the king’s battle
robe was probably a plaid of goat’s hair.
The tunic was crossed over the breast and
ornamented with embroidery. This can be
faintly discovered on the stone, and has
been reproduced at the top and bottom of
this page.

COPVRir»HT

Ixx

TEXTUR/E ANTIQUE, 5 — AKKADIAN

Ixxii

ADVERTISEMENTS

good reasons
why Lemco is so
highly valuable
in invalid-diet

Lemco contains ; —

1. MINERAL SALTS - - • 19.38 per cent.

I NITROGEN 10.64

3. ALBUMOSE 14.08

4. PEPTONE 5.76

5. CREATINE AND CRE.ATININE - 14.28

6. SOLUBLE ORGANIC MATTER 18.31

These figures, which were obtained in The Lancet
laboratory, are evidence of the high analytic
and dietetic standard of Lemco. Nothing but
prime fresh beef, obtained from the Company’s own
cattle^ — is used in its manu-
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Lemco, Thames House, London, E.C.

♦y

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is:

*•••

THE

MEDICAL ANNUAL

THE

MEDICAL ANNUAL:

A YEAR BOOK OF TREATMENT
AND PRACTITION

Sir CHAS. bent BAL,Iy, Bart.. M.ch. f.r.c.s. i
JOSEPH G. BLUMFEED, b.a. ‘ m.d. j Sir

VICTOR BONNEY, M.S., m.d., p.r.c.s. M.S., f.r.c.s.

FRANCIS D. BOYD, c.M.a,, m.d., f.r.c.p. Prof. CARE VON NOORDEN, Frankfurt

EAWRAvSON BROWN, M.D., New York EDW. N. PACKARD, Jdn., Ph.B., M.D..

FRANCIS J. CHARTERIS, m.b., B.ch. New York

Sir JOHN COEEIE, m.d. JOS. J. PERKINS, m.a., m.b., f.r.c.p.

CAREY F. COOMBS, M.D., m.r.c.p. BEDFORD PIERCE, m.d., f.r.c.p.

Prof. "WTEHEEM FAETA, Vienna W. G. PORTER, m.b., b.sc., f.r.c.s.

HERBERT FRENCH, m.a., M.D.Oxon., f.r.c.p. JOSEPH PRIESTEEY, b.a., m.d., d.p.h.
BRYDEN GEENDINING, m.s., m.b., f.r.c.s. GEORGE E. RICHARDS, m.d., Fall River,
EDWARD W. GOOD.AEE, m.d., b.s. Massachusetts.

ERNEST W. HEY GROVES, M.D., M.S., PROF. EEONARD ROGERS, Maj. r.M.P., .m.d.,
F.R.C.S. . P.R.C.S., Calcutta

OSKAR C. GRUNER, m.d. Eond., Montreal J. S. KEEEETT SMITH, f.r.c.s.

C. THURSTAN HOEEAND, M.R.C.S., I..R.C.P. - PURVES STEWART, M.A., M.D., f.r.c.p.
ROBERT HUTCHISON, M.D., f.r.c.p. A. HUGH THOMPSON, M.A., M.D.

FREDERICK EANGMEAD, m.d., f.r.c.p. BEVEREBY R. TUCKER, M.D., Richmond,
PRIESTEEY EEECH, m.d., f.r.c.s. Virginia

E. G, GRAHAM EITTEE, m.d., f.r.C.p. j HAROED UPCOTT, f.r.c.s.

CHAREES FRED. MARSH.ALE, m.d., f.P-.c.s. I J. W. THOMSON WAEKER, f.r.c.s.

1914

THIRTY-SECOND YEAR

BRISTOL: JOHN WRIGHT & SONS LTD.

* LONDON: SIMPKIN, MARSHALL. HAMILTON. KENT & CO. Ltd,
NEW YORK: E. B. Treat & Co.; TORONTO: The J. F. Hartz Co. Ltd,
CALCUTTA: Thacker, Spjnk & Co.; Botterworth & Co. (India) Ltd.
BOMBAY : Thacker & Co. Ltd.

MELBOURNE, SYDNEY, ADELAIDE and BRISBANE :

G. Robertson & Co. Proprietary Ltd.

SYDNEY: Angus & Robertson Ltd, NEW ZEALAND: Whitcombe & Tombs Ltd-

Ixxvi

ADVERTISEMENTS

KEROL

DISINFECTANT and ANTISEPTIC Preparations.

KEROL combines all the properties which go to the making
of an ideal disinfectant preparation.

It is sixty times less toxic than phenol when its germicidal
power is taken into consideration (vide MEDICAL TIMES/'
28th June, 1908).

It is non-corrosive and non-irritant, so it can be used with
•perfect confidence where a disinfectant or antiseptic is indicated.

It is of high and guaranteed germicidal value, and is perfectly
homogeneous.

KEROL CAPSULES,

For internal use Kerol is put up in two forms of capsule
<intestinal and stomachic) and most excellent results have been
obtained by their use.

They reduce the coli content of the intestine by 99 per cent
when they have been administered for 10 days (MEDICAL Press,
Jan. 14th, 1914).

The following are extracts from some of the opinions we have
received as to their clinical value : —

GOUT AND RHEUMATISM (Intestinal Toxaemia).

“ I nave had many attacks of my ailment and got well, but I nave
never made such rapid progress.’*

NEURASTHENIA.

" I nave used Kerol Capsules in cases of neurasthenia with atonic
flatulent dyspepsia with good results.”

L.R.C.P., L.R.C.S.

“ The symptoms were chiefly nervous manifestations, lassitude and
intestinal flatulence and loss of appetite. She had been treated by
prominent physicians in Edinburgh without improvement. After a short
treatment with the capsules she informed me she was quite sure I was
the only one who really understood her illness. In six weeks she was in
excellent health, agam resumed nursing, and has been employed con- •
tinually ever since-now a period of a year and a half.”

M.B., Ch.B.

Latest literature showing the bacteriological and clinical value
of Kerol Preparations, together with sample will be sent to any
registered Medical Practitioner free on application.

QUIBELL BROS, ua., m Castie Gate, NEWARK.

Omitted in Ertor.

JOHN BURDON-COOPER, M.D., B.Sc., D.O. Oxon.

Senior Surgeon Bath Eye Inflnnaiy PATHOLOGY OF CATARACT

Contributors and Original Contributions to
Medical A nnual, igi4.

Sir CHAS. BENT BALL, Bart., M.D., M.Ch., F.R.C.S.I.,

Hon. F.R.C.S. Eng.

Honorary Surgeon to H.M. the King in Ireland ; Reghis Professor of Surgery,

University of Dublin ; Surgeon, Sir P. Dun’s and Simpson’s Hospitals, Dublin

Rectal Surgery

JOSEPH G. BLUMFELD, B.A., M,D.

Senior Anaesthetist, St. George’s Hospital ; Honorary Anaesthetist, SI, Mary’s
Hospital Anaesthesia

VICTOR BONNEY, M.S., M.D., F.R.C.S., B.Sc.

Assistant Obstetric and Gynaecological Surgeon, Middlesex Hospital : Surgeon,

Chdsea Hospital for Women ; Gynaecolo^cal Surgeon, Hospital for Nervous
Diseases, Maida Vale Gynjecology AND OBSTETRICS

FRANCIS D. BOYD, C.M.G., M.D., F.R.C.P. Ed.

Physician, Royal Infirmary, Edinburgh ; Consulting Physician, Deaconess
Hospital, Edinburgh ; and Senior University Decturer on Clinical Medicine,
Edinburgh ReNAL AND URINARY DISEASES

LAWRASON BROWN, M.D., New York.

Tuberculin in Treatment

FRANCIS J. CHARTERIS, M.B., B.Ch.

Decturer on Materia Medica and Therapeutics, University of Glasgow ; Assistant
Physician, Western Infirmary, Glasgow

Materia Medica and Therapeutics

Sir JOHN COLLIE, M.D.,

Member of Advisory Committee, National Insurance Act, 1911 ; Medical
Examiner, D-C.C., etc. MALINGERING

CAREY F. COOMBS, M.D., M.R.C.P.

Assistant Physician, Bristol General Hospital

Diseases of the Heart and Blood-vessels

Prof. WILHELM FALTA, Vienna.

^ Assistant to the first Medical Clinic in Vienna

Thorium and Mesothorium

HERBERT FRENCH, M.A., M.D. Oxon., F.R.C.P.

Physician, Pathologist and Decturer, Guy’s Hospital GENERAL Medicine

BRYDEN GLENDINING, M.S., M.B., F.R.C.S,

Obstetric and Gynaecological Tutor, Middlesex Hospital ; Pathologist, Chelsea
Hospital for Women GYNAECOLOGY AND OBSTETRICS

ixxviii

CONTRIBUTORS AND ORIGINAL CONTRIBUTIONS

EDWD. W. GOODALL, M.D., B.S.

Superintendent of the Eastern Hospital, Homerton

Acute Infectious Diseases

ERNEST W. HEY GROVES, M.D., M.S., F.R.C.S.

Hunterian Professor, R.C.S. (1014) ; Surgeon, Bristol General Hospital ; Senior
Surgeon, Cossham Hospital, Kingswood

Surgery of the Nervous System

OSKAR C. GRUNER, M.D. Lond., Montreal.

Pathologist at the Royal Victoria Hospital, Montreal ; Assistant Professor of
Pathology at the McGill University, Montreal CLINICAL PATHOLOGY

CHARLES THURSTAN HOLLAND, M.R.C.S., L.R.C.P.

Honorary Medical Officer Electrical Department, Royal Infirmary, Liverpool

Radio-activity and Electro-therapeutics

ROBERT HUTCHISON, M.D., F.R.C.P.

Physician, London Hospital ; Physician, with Charge of Out-patients, Hospital
for Sick Children, Great Ormond Street

Gastro-intestinal Disorders

FREDERICK LANGMEAD, M.D., F.R.C.P.

Physician in Charge of Out-patients, St. Mary's Hospital ; Assistant Physician,

Hospital for Sick Children, Great Ormond Street

Medical Diseases of Children

PRIESTLEY LEECH, M.D., F.R.C.S.

Senior Surgeon, Royal Infirmary, Halifax . GENERAL SURGERY

E. G. GRAHAM LITTLE, M.D., F.R.C.P.

Physician for Diseases of the Skin, St. Mary’s Hospital and East Loudon Hospital
for CliildTen ; Lecturer on Dermatology, St. Mary’s Hospital Medical School ;

Member of the Senate of the University of London Skin DISEASES

CHARLES FRED. MARSHALL, M.D., F.R.C.S.

Late Surgeon to the British Skin Hospital VENEREAL DISEASES

KEITH W. MONSARRAT, M.B., C.M., F.R.C.S.

Lecturer'on Clinical Surgery and Dean of the Faculty of Medicine, University of
Liverpool ; Surgeon, Northern Hospital, Liverpool Cancer

Sir BERKELEY G. A. MOYNIHAN, M.B., M.S., F.R.C.S.

Surgeon, Leeds Infirmary ; Professor of Clinical .Surgery in the University of

Abdominal Surgery

Prof. CARL VON NOORDEN, Frankfurt.

Thorium and Mesothorium

EDW. N. PACKARD, Jun., Ph.B., M.D., New York.

Tuberculi.n- in Xre.atment

Ixxix

CONTRIBUTORS AND ORIGINAL CONTRIBUTIONS

JOSEPH J. PERKINS, M.A., M.B., F.R.C.P.

Physician, St. Thomas’s Hospital ; Lecturer on Medicine, St. Thomas’s Hospital
Medical School ; Physician, Hospital for Consumption, Brompton

Pulmonary Diseases

BEDFORD PIERCE, M.D., F.R.C.P.

Medical Superintendent, The Retreat, York j Lecturer on Mental Diseases,
University of Leeds Mental DISEASES

W. G. PORTER, M.B., B.Sc., F.R.C.S.

Surgeon, Eye, Ear and Throat Infirmary, Edinburgh ; and to Ear and Throat
Department, Royal Hospital for Sick Children, Edinburgh ; Aurist, Edinburgh
Royal Institute for Deaf and Dumb

Diseases of the Nose and Throat

JOSEPH PRIESTLEY, B.A., M.D., D.P.H.

Medical Officer of Health for the Metropolitan Borough , of Lambeth ; Lecturer,

Royal Sanitary Institute

Public Health : including Forensic Medicine.
State Medicine, Hygiene, Industrial Diseases,
and Toxicology

GEO. L. RICHARDS, M.D., Fall River, Mass.

Surgeon for the Ear, Nose, and Throat to the Union and St. Anne’s Hospitals in

Fall River DISEASES OF THE EaR

LEONARD ROGERS, Major I.M.S., M.D., F.R.C.S.

Professor of Patliologj'', Medical College, Calcutta

Tropical Diseases, including Pellagra

J. S. KELLETT SMITH, F.R.C.S.

Spinal Deformities : their Treatment by Exercises

PURVES STEWART, M.A., M.D. Ed., F.R.C.P.

Physician to the Westminster Hospital ; to the West End Hospital for Nervous
Diseases ; and to the Royal National Orthopaedic Hospital ; Lecturer on Nervous
Diseases, Westminster Hospital Medical School Nervous Diseases

A HUGH THOMPSON, M.A., M.D.

Surgeon to the Western Ophthalmic Hospital Eye DISEASES

BEVERLEY R. TUCKER, M.D., Richmond, Virginia.

Pellagra : as seen in America

HAROLD UPCOTT, F.R.C.S.

Honorary Assistant Surgeon, Hull Royal Infirmary

Abdominal Surgery

J. W. THOMSON WALKER, F.R.C.S.

* Surgeon to North West London and Hampstead General Hospitals ; Assistant
Surgeon to St. Peter’s Hospital for Stone and other Urinary Diseases ; Urinary*

Surgeon to Radium Institute URINARY SuRGERY

Ixxx

ADVERTISEMENTS

DR. BARNARDO’S

HOMES.

CHARTER :

“ No Destitute Child Ever
Refused Admission.”

NO WAniNQ LIST.

NO VOTES REQUIRED.

NO RED TAPE.

A FEW FIGURES.

78,300 Children have passed through the Door that always Opens.
1,666 entered last year.

8.000 Boys and Girls of all ages are always in the Homes.

1.000 of* these are Infants.

1,000 are Crippled, Incurable, Blind, Deaf and Dumb, or physically
afflicted.

4,500 are Boarded-out in Rural Districts in England and Canada.
900 Boys and Girls are under Industrial Training.

300 Boys are in training for the Navy and Mercantile Marine.
25,360 Young People have been emigrated to the Colonies.

Nearly 1,000 sent to Canada yearly. 95 per cent, do well.

The average death rate in the Homes, during 1913,
was remarkably low — 5.10 per 1,000.

Cheques and Orders payable DR.BARN ARDO'S HOMES,"
may he sent to the Honorary Director, WILL! AM BAKER, M.A.,
LL.B., 18 to 26, STEPNEY CAUSEWAY, LONDON, E.

CONTENTS.

PAGE

Contributors and Sections ..... Ixxvii

Preface ........ Ixxxiii

General Index ...... Ixxxvii

Glossary ........ cxxxv

Review of Therapeutic Progress, 1913 . . , . i

Dictionary of Remedies ...... 1-37

Radio-activity and Electrotherapeutics . . .38

Tuberculin Therapy . . . . . . 68

Review of Medical and Surgical Progress, 1913 . . 77

Dictionary of Treatment . . . . . .84

Anjesthetics ....... 102

Blood Examination ...... 147

Brain Surgery . . . . . . -155

Bronchoscopy ....... 166

Cancer . , . . . . . .175

Fractures ........ 242

Surgery of the Lung ...... 344

Malingering ....... 353

Pellagra ........ 416

Artificial Pneumothorax ...... 445

Lateral Spinal Curvature ..... 528

Suggestion in Therapeutics ..... 558

Syphilis ^ . . . . . . . . 568

Tuberculosis , . . . . . .623

Public Health ....... 670

Medico-legal and Forensic Medicine . . . .670

State Medicine ....... 673

Legal Decisions affecting Medical Men, etc. . . 677

Industrial Diseases .\nd Toxicology .... 685

Editor’s Table — New Inventions and Prep.\r.\tioxs . . 688

Books of the Year ...... 733

Establishments for the Treatment of Mental Diseases . 752

Sanatoria for Tuberculosis ..... 761

Institutions for Inebriates . . ... . 765

Hydropathic Establishments ..... 767

Nursing Institutj^s and Homes . . . . .768

Spas, Principal British . . . . . .770

Official Directory. ...... 776

Educational Vaccination Stations , , , . 77S

Medical and Scientific Societies, and Periodicals . . 779

Directory, Medical Trades . . . . . 783

Private Notes and Addresses . . . - 7^7

Life Assurance Offices, List of . ' . . . . 797

Index to Advertisers . cxxvi ^

Ixxxi;

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PREFACE

The past year has been one of exceptional activity in
all departments of medical science. Exact details of
technique — diagnostic, clinical, and surgical — have
formed the subject of a large number of contributions.
It has always been difficult to provide a ready means
of reference to the information thus afforded and, at
the same time, keep the volume within convenient
size. This year we have been compelled to add about
one hundred extra pages. We hope that this will
not be regarded as a permanent increase in the size
of the Annual.

Every article is carefully studied with a view
to rendering it as concise as possible, because we
recognize that in this form it is most useful to the
profession; but we cannot omit matter which any
section of our readers may regard as important.

Fortunately, our subscribers steadily increase in
numbers: these are not confined to any country,
and although some of the diseases described in this
volume may never come under the notice of the
practitioner in Great Britain, we should be sorry to
suppose that he desired no information concerning
them. Moreover, it is because we have tried to
make the Annual entirely cosmopolitan that we are
able to obtain the ready help of the leaders of
medical thought and research in all parts of the
world.

I xxxi%"

PREFACE

Science has no geographical boundaries, and it
is only necessary to glance through the names of
contributors to the pages of the Annual to realize
that nationality has little influence upon medical
progress. We represent a universal fraternity having
objects and methods in common, and whose results
are of equal interest to all.

Everyone concerned in the production of the
thirty-second issue of the Medical Annual has
striven to make it worthy of the kind reception
^ven to its predecessors.

The Editor. •

The “Medical Annual” O'ffices,

Bristol, February, 1914.

ADVERTISEMENTS

Ixxxv

Valentine’s Meat-Juice

In all Wasting, Acute or Febrile
Diseases, where the Digestive Organs
are Impaired, Valentine^s Meat-
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Strengthen

When Other
Food Fails

The quickness and
power with which
Valentine's
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the manner in
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self to and quiets
the stomach, its
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ease of administra-
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it the approval
and endorsement
of many medical
men of Europe,
America, etc.

VALENTINE’S MEAT-JUICE CO

RICHMOND, VIRGINIA, U.S.A.

advertisements

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GAUTIER FRERES’.

<»9° FINE OLD ®?°

LIQUEUR BRANDY.

(Guaranteed 20 Years Old.)

Extract from The Eancet, 14th August, 1897.— The
product before us, being a genuine grape spirit and
possessing those estimable diameters in regard to aroma
and flavour of real Cognac Bmndy, is peculiarly well
adapted for medicinal purposes.”

Extract from Tiis Hospital, 14th August, 1897.— “It
is a brandy highly suitable for general use or for medidnal
purposes when a liqueur brandy is desirable.”

I Apply to BROWN, GOI^E & Co. {Wholesale Agents only)
40, Trinity Square, E.C., for name of nearest Dealer.

CAUTIER FRERES, Cognac, Established 1755.

Of Wine Merchants and Stores;
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V Brown, Gore Sc Co. will be happy to send a Sample

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b-O-O-O-O-O-O-O-G-O-OOC^O-O-O-O-O-O^-O-O-OO-O-O-OC

General Index :

The mote important articles are in heavy type.

PAGE

BDERHAIyDEN’S test in diagnosis
of pregnancy . . , . 150, 453

Abdomen, gnnsbot ■womids of . . 84

Abdominal aorta, aneurj’sm of . . . . 112

— muscles, relation to spinal deformity 530

— operations, new clamp for . . . . 693

— retractor, new designs . . . . 713

— surgical, general review of . . . . 77

Abdominal wall, ligrneotts phleg-
mon of 85

Abduction in operation for fractuie 244, 248
Abel’s bacillus in ozaena . . . . . . 384

Abortifacients, small value of volatile

oils as . . , . . . . . 9

Abortion, relation of sale of diachylon to 685

— erystypticin in treatment of . . 9

— indications for in pregnancy toxiiemia

456, 457

Abscess of bone, A'-ray diagnosis of . . 43

— the brain 155

due to araoebsB . . . . , . 91

— cold, action of carbenzyme on . . 6

— cerebellar, differentiation from laby-

rinthitis ^ . 335

— cer\dcal 404

— intramural, treated by hysterectomy 661

— of lesser sac following pancreatitis . . 4:2

— liver, amoebic, emetine in . . . . 93

in India . . . . . . . . 91

— lung 347

Abscesses, vaccine treatment of . . . . 36

Acanthosis nigricans . . . . . . 83

Accidents, diseases classed as . . . . 671

Accommodation, errors of . . . . 483

Aceto-salicylic acid in rheumatoid ar-
thritis .. .. .. ..125

Acetone in urine, test for . . . . G56

Acet vl-aceto-sai icy i- Irichlor-isob u t yl-cst cr

in gout . . . . . . . . 271

Achj'lia gastrica, analysis of duodenal

contents in.. .. .. .. 412

in children.. .. ,. .. 215

— pancreatic, character of faeces in . . 236

Acid intoxication, salicylates in causa-
tion of . . . . . . . . 491

— sodium phosphate, action on urine of 32

in enuresis . . . . . . 229

urinary infections . . . . 654

Acid, sulph. dil.’in funuiculosis. . 254

Acidosis in pregnancy . . . . . . 455

— and the question of operation . . 205

Acitrin as uric acid eliminant . . i, 734
Acne, ichthyol in .. .. ..511

— ionic medication in . . . . . . 59

— resorcin in . . . . . , . , 507

— rosacea, new method of applying

sulphur . . . . . . . . 31

sulphur in 510

— sub-aural, precocious .r-ray reactions

after treatment . . . . . . 49

— thymus extract in . . . . . . 515

Acne vulgaris 86

P.^GE

Acne vulgaris, vaccine therapy in 36, 513
Aconite, belladonna, and cliloroform in

fibrositis . . . . . . . . 239

— effect on pulse-rate . . . . . . i

— in gonorrheea . . . . . . . . 267

Aconitine, rapid deterioration of . . 3

Acromegaly, relation of dyspituitarisra

^ to . . ^ 435, 437

Actinomycosis 96

— vaccine treatment of 87

Adalin as sedative . . . . . . 724

Adamon. a bromide-valerian sedative. . 724

Addison’s disease . . . . . . . . 88

a contraindication for salvarsan. . 574

Addresses of nurses, etc. . . 793, 794

Adenitis, chronic, A-ray treatment of . . 48

— after removal of adenoids . . . . 88

Adenoids 88

— colloidal silver in . . . . . . 30

— in etiology of otitis media . . . . 401

rheumatism in childhood , . 492

— removal of, in cure of enuresis . . 22S

— x-ray treatment of 49

Adenomatous enlargement of prostate. . 43 S

Adhesions, peritoneal, methods of pro-
moting 432

Adigan, a new digitalis preparation . . 8

Adiposity, effect of pineal and pituitary

glands on 433. 437

— lept^mol for . . . . . . . . 15

Adolescent albuminurics and life insur-
ance.. .. .. .. .. 88

Adrenal extract (see Suprarenal)

Adrenalin in anresthesia for spinal surgery 524

— asthma of children . . . . . . 130

— cholera.. .. .. .. .. 193

— enuresis, of little value . . . . 229

— haemorrhages of the newly-born . , 273

— injection, danger with light chloro-

form auffisthesia . . . . . . 106

— in nephritis . . . . . . . . 2

— non-corrosive poisoning cases . . a

— pernicious vomiting . . . . . . 456

— aihd pituitriii, good results of com-

bining . . . . . . . . 24

— in urticaria . . . . . . . . 659

— whooping-cough . . . . . . 433

Adrenalinoemia theory of hypertension. . 374

— A-rays in .. .. ..154

Adrenalin-cocaine direct injections in

asthma and bronchitis . . . . 224

Aduiteiatic.:! cf food, legal decisions re 677
Aerophagy in angma pectoris, treatment 1 14
After-care in rheumatic cjaralli:r . . 282
Agar jelly bougies in gonorrheea . . 370

Agehylostoma ceylanicum, description of 649
Age, importance of, in treating spinal

curvature . . . . . . . . 529

— incidence in pdlagra.. .. 417, 425

tuberculosis in cliildhood . . . , 624

Agglutination tests in typhoid fever . . 641

Agmel for renal and urinary inflarama tion 725

Ixxxviii

GENERAL INDEX

PAGE 1 PAGE

Ague, brassi'foimdcr'i’ . . . . . . r>S6 Aiiajmia, splenic, ,'r-ray treatment of . , 47

Airo (oxy-iodo-gallaleol bismulli powder) 745 Ansemic subjects, operations on. . . , 103

Air-passages, relation to rheumatism in Antesthesia in bronchoscopy and oeso-

childhoocl 492, 494 phagoscopy i6y

Aix douche and massage in gonorrhoeal — examination of patients before . . ro7

arthritis .269 — hysterical, suggestion treatment in . , 565

rheumatoid arthritis . , . . 125 — inhalation 102

Albimiin content of cerebrospinal fluid . . 189 — intratracheal 104

puncture fluids . . . , . . 468 apparatus for 695

— and pus in urine, relation between . . 658 — intravenous . . 107

— reaction in sputum 547 — in laryngeal tuberculosis . . . . 331

— in rectal feeding . . . . . . 483 — local, for enucleation of eyeball . . 234

Allbtimixi'uria 88 and regional 108

— adrenaUu and . . . . . . , . 2 — of mucous membranes, permanganate

— cataract associated with . . . . 185 - of potassium producing . . . . 23

— cyclic, with intestinal dyspqpsia of — paralysis 107

diildren 215 — by pharyngeal insufflation . . . . 106

— with diseased tonsils 616 — spinal, favourable reports on . . 107

— in pregnancy . . . . . . . . 455 in prostatectomy . . . . . * 460

Alcohol in arteriosclerosis . . . . 121 — in spinal surgery . . . . . . 524

— etiology of gastric cancer .. .. 549 Antesthetic, local, new thymol derivatives as 3:

glycosuria 203 Anaesthetics 102

laryngeal paralysis . . . . 331 — general review of 77

— injections in laryngeal tuberculosis.. 331 — in operation for exophthalmic goitre 609

trigeminal neuralgia . . . . 377 Ansesthetization in operations on thorax 346

in intestinal dyspepsia of children . . 2r6 Anal fissure as cause of enuresis. . . . 228

Alcoholism, suggestion treatment of . . 565 etc., ionic medication in . . . . 59

Alcucocythaemic leukjEmia .. .. 336 Analgesic, aleudrin as an 3

Aleudrin as a sedative and hypnotic . . 2 Analgesics, local, with general anaesthetics 103.

Alkalies in intestinal dj’-spepsia of children 216 Analysis of pancreatic ferments . . 411

Alkaline baths in psoriasis .. .. 464 Anaphylactic reaction in cancer diagnosis 175

— es^ectorants for stout bronchilics . . 166 Anaphylaxis in tuberculin treatment . . 68

Alkalinity of blood serum in cancer Anastomosis, arterio-venous .. .. 119

patients 176 — of nerve roots 527

Allantoin dressing after mastoid operation 403 — saphenous-femoral, for varix . , 665

AUyl sulphide in tuberculous joints, etc. 3 ' Anchorion violaceum, a new variety of

Aloes in intestinal dyspepsia of children 216 favus 497

Alopecia areata 89 Andaman Islands, new form of malaria in 353

— ionic medication in 59 Anemic pseudo-chlorotique . . , . 95

Alum month-wash in measles .. .. 363 Aneurysm of abdominal aorta .. .. 112

AJun^ym acetate in eczema . . . , 230 — dissecting, cause of . . . . ,.109

Alypin in spinal analgesia . . . . 107 Aneurysm, intrathoraoic . . 108

Amenorrhoca, glanduovin in .. .. ii course no

— production by .T?-ra3’s . . .. .. 45 etiology .. .. .. .. 108

Amentia, relation to congenital syphilis 598 S3"mp toms and diagnosis. . .. 109

Amido-azotoluol after mastoid operation 403 treatment'.. .. .. .. no

— excessive epithelialization ingrafts A'-ray diagnosis of . . .. .. 43

dressed with .. .. .. 51S — of subdavian and iunominate arteries 113

Amidosulphuric acid iu prophylaxis of — superficial palmar arch .. .. itz

cholera . . . , . . . . 192 — syphilitic . . . . . . . . 276

Amino-adds in rectal feeding . . . . 483 — vein-grafting after excision of . . 120

Amoehiasis {see also Dysenterj^) . . 90 — Wassennann test in 573

— emetine as spedfic in . . .. 83,91 Aneurysm, surgery of .. .. 112

Ammonia carbonate for stout bronchitics 166 Angina pectoris 114

Ammonia-nitrogen in urine, tests for . . 657 Angina, Plant- Vincent, salvarsan in . , 385

Amorphous cinchona alkaloid in malaria 353 Angiomata, cavernous, carbon dioxide

Amputations 94 snow in 313

— in gangrene of extremities . , . . 255 — of spinal cord 321

— for mycetoma , . . . . , . . 369 Angioneurotic cedema, " blue brain a

Amylase in duodenal contents in pan- mild fonn of . . . . . . 548

creatic and gastric diseases 412,413 organotherapy in . . .. .. 515

— test for, in pancreatic secretion .. 41 1 Animal organism, effect of thorium on .. 64

Amylolytic ferment in urine, test for . . 658 Animals, wild, in etiology of sleeping

Anaemia iu children . . . . 95 sickness 620

— effect of thorium-x in. . .. 66 Ankylosis of liip, production of . . .. 295

— from hookworm disease . . . . 649 Ankylostomiasis {see Undnariasis) . . 649

— infective splenic, on the Mediterranean 96 Ankylostomum, ' differentiation from *

— malaria.. .. .. .. .. 352 Neqalor americanus .. 649

— and pallor, importance of distin- ’ Anod-assodation in abdominal surgery 77

guisbing between 96 — major surgery. . 104

Anaemia, jpgrBicious . . . . 98 — sjriinge for injections for , . . . 702

7..-C2us^in children 96 Anopheles in relation to malaria .. 350

rdatioTi to bone-marrow cancer. . 98 Anorexia in diagnosis of gastric cancer. . 549

- — ■— salvarsan in 99 Anovarthyroid serum, therapeutic action s

r-.A Anthdmintic, wermolin as an ,. .. 37

Anthrax 114

— bacilli in cerebrospinal fluid . . . . 190

— industrial, Home Office inquiry into 687

— splenic 544 ' Antiluelin in syphilis 580

— — iw*. * * • « « «

— — tliOTium-:*; in . . • . , , loo

— severe, defibrinated blood injections in 4

— with spinal curvature, treatment . . 540

GENERAL INDEX

Ixxxix

PAGE

Antimony in sleeping sickness .. .. 621

Antineuralgic drugs in sciatica . . . . 502

Antipertussis vaccine . . . . . . 433

Anti-plague serum, trials witli . . . . 440

Antipyrin in gonorrhoeal arthritis . . 268

— of little value in enuresis .. .. 229

Antiseptic, dilormetacresol as a . . . . 6

— new thymol derivatives as . . . . 31

— noviform as an . . . . . . 19

— oKoline as an . . . . . . . . ^^30

Antiseptics, experiments on relative

value of . . . . . . . . 33

— in operation for cataract . . . . 183

— urinary 654

Antistaphylococcic serum, good results 29
Antisvphilitic serum in general paralysis

591, 596

Antithyroidin, disappointing in Graves’

disease ' . . 264

Antitoxin treatment {see Serum)

Antityphoid inoculation . . . . . . 645

Antivenencs in snake-bite .. .. 518

Antral suppuration, ionic medication in 59
Anuria, calculous, surgical treatment . . 315

Anus, diseases of 115

Anxiety, aleudrin as sedative in . . 3

Aorta and heart, syphilis of . . . . 275

— occlusion of, in aneurysm . . . . 113

Aortic insulficienc5'', Wassermann test in 572
Aphonia, hysterical, suggestion treat-
ment in 565

Apical catarrhs, etc., diagnosis from

phthisis 629

— tuberculosis, relation of changes in

first rib to 344

Apiol, oil of, small value as emmenagogue 9
Apocynum cannabinum in cholera . . 194

Apoplexy, operation for 158

Apenta water in intestinal dyspepsia of

children 216

Appendicitis 115

— Abderbalden’s test in 152

— as an accident 671

— complications of .. .. 116

Appendicitis, clironic .. 117

rectal palpation in . . . . x 17

— chylous cysts of mesentery simulatmg 368

— errors in diagnosis . . . . . . 115

— rdation of pericolic membranes to.. 430

— vaccine therapy in fistula following . . 36

Appendix, retrograde, incarceration of 290
Appliances, new medical and surgical . . 689

Argas persicus in etiology of relapsing

fever . . . . . . . . 541

Argyll-Robertson pupil test in cerebro-
spinal syphilis . . . . . . 587

Argj'ria, colloidal silver non-productive of 30
Argyrol in EJustachian catarrh . . . . 395

Arm, test of malingerers for weakness of 356
Aristol in otitis media . . . . . . 400

Ametli blood count in tuberculosis 148, 623
as guide to tuberculin treat-
ment '75

Arrhythmia, varieties of 279

Arsenic in asthma of children . . . . 130

acanthosis nigricans 85

— antemia in children . . . . . , 97

— contraindicated in chorea . . . . 495

— in pernicious aiiffimia . . .. lox

— pellagra 418, 427

— psoriasis 464

— tinnitus. . , . . . . . . . 613

Arsenical cancer 119

— compounds in syphilis of nose and

throat 385

Arsenite of silver, therapeutic indications 3
Arterial disease, cholesterin in blood in X49

— - — of intermittent limp . . . . 122

— hypertension (see Blood Pressure)

PACE

Arterial hypertension in nephritis . . 37.3

x-XQ.y teratment . . . . . . 48

— hypotension in scarlet fever, supra-

renal extract in . . . . . . 501

— pressure in infancy . , , . , . 153

Arteries, ligation of, in Graves’ disease. . 610

Ai'teries, surgery of .. .. 119

Arteriosclerosis 12 1

— as cause of aural vertigo , . . . 666

— and nephritis . . . . . . . . 374

— association of erytlirseinia with . . 452

— operation in gangrene due to . . 255

Arterio-venous anastomosis .. .. 119

Arthritis, acute, massage in . . . . 16

— deformans, identity with rheumatoid

arthritis 123

— gonorrhoeal, treatment . . . . 268

— ionic medication in . . . . . . 59

— pneumococcal, vaccine therapy in . . 36

Artliritis, rlieuuiatoidl . . . . 123

bacteriology of . . . . . . 126

premonitory vasomotor signs . . 133

— syphilitic 127

Arthrotomy in gonorrhoeal arthritis . . 268

Articular rheumatism . . . . . 490

Articulation test in cerebrospinal syphilis $87
Ascoli’s thermo-precipitin reaction in •

phthisis . . . . . . . . 623

Aseptic instruments, new methods of

securing . . . . . . . . 689

Aseptoid mcjcuric soap . . . . . . 723

Asphyxia! conditions, acute, oxj’gen in-
jections in 2t

Aspiration and quinine injection in liver

abscess 94

— in subdeltoid bursitis. . . . . . i7r

Aspirin in fibrositis . . . . . . 238

— gonorrhoeal arthritis . . . . . . 268

— rheumatoid arthritis 125

Astasia-abasia, suggestion treatment in 565
Astigmatic children, frequently becoming

myopic 483

Asthma X28

— bronchial, vaccine therapy in . . 165

— effect of nasal operation in . . . . 12 S

— endo-bronchial treatment of . . 224

— treatment 129

Astringent, noviform as an . . . . 19

Asymmetry, congenital, malingerers and 357
Ataxia, effect of salvarsan on . . . . 592

Atophan in gout . . . . , . . . 271

— skin rashes produced by . . . . 4

Atoxyl in endemic anaemia of children . . 97

— sleeping sickness .. .. .. 621

Atropine in cancer of oesophagus . . 388

— congenital pyloric stenosis . . . . 476

— effect on paroxysmal tachycardia . , 285

— in gastric ulcer . . . . . . 258

Attitude, cliaracteristic, in thoracic aneu-
rysm 109

Auditory nerve, degeneration of . . .. 327

division in tinnitus . . . . 6x3

Aural diseases (see Bar)

— polypus a cause of cough . , . . 199

— suppuration, chronic, treatment of . . 400

— vertigo, causes and treatment , . 666

Auricnlar enlargement as cause of

laryngeal paralysis . . . . 331

Auricular fibrillation . . . . X30

action of digitalis in . . . . 2S3

Auricular flutter 131

Auscultation, D'Espine's method, in

tuberculous bronchial glands .. 163

— in heart disease 279

Auto-intoxication in causation of uveitis 307
Auto-suggestion, curative use of . . 562

Avulsion of intercostal nerves for

visceral crises 526

Azodolen dressing af ter mastoid operation 403

GENERAL INDEX

PAtlE

B all, Sir C. B„ 115, 478 : Blumfeld,

J, G., 102 ; Bomiey, V., 102,

323, 365, 400, 453, 455, 498, 654,

659, 662, 664 ; Boyd, F, D., 88,

200, 201, 373, 463, 485, 654 ;
Browti, 1^., 68 ; Burdon-Cooi^cr,

Jm 184

Bacilli in blood-stream in tuberculosis . . 622

— aerogeiies capsulatns as cause of

gangrene 255

— acidi lactici sprays in diphtheria . . 211

— acne, clinical manifestations of . . 86

— bulgaricus in infantile diarrhoea . . 208

diabetes . . . - . . . . 204

— coli in causation of pyelitis in children 469

infections and heart-block . . 288

mercury injections in. . . . 18

vaccine therapy in . . . . 34

— human and bovine, in etiology of

tuberculosis . . . . ” . . 636

— influenzae, association with ulcerative

endocarditis . . . . . . 225

— lepree, action of radium on . . . . 53

— paratyphosus, epidemiology of . . 414

— ^ pertussis, treatment by . . . . 433

— of plague, experiments with , . . . 437

— proteus, fatal septicaemia due to . . 505

— pyocyaneus, generalized infection due

to 505

— typhosus {see Tj’phoid Fever) . . 638

Back, examination in suspected malin-
gering 358

Backward children, medical gymnastics

for 17

pineal gland extract for . . . . 434

Bacteria, effect of hydrogen peroxide on 13

thorium on 63

— iodophile, relative content in intestines 236
Bacterisemia, staphylococcic, serum

treatment of . . . . . . 29

Bacterial food poisoning. . .. .. 673

— infections, insect porters of . . . . 673

— origin of uveitis . . . . . . 307

Bactericidal properties of ultra-violet

radiation 55

Bactericide, resorcin as a . . . . . . 507

Bacteriological bench, new form of . . 691

Bacteriology of acne, comedo, etc. . . 86

— acute rheumatism . . . . , . 490

— cerebrospinal fluid . . . . . . 189

— diagnosis of gonorrhoea . . . . 266

— of Darier’s disease 311

— epidemic poliomyelitis . . . . 450

— goitre 261

~ leprosy . 333

— osteomyelitis of spine. . , . . . 541

— otitis media . . . , , . . . 395

— ozsena . . . . . , . . . . 410

— pellagra 423

— pemphigus 427, 428

— pertussis . . . . . . . . 433

— pseudo-glanders . . . . . . 258

— pyelitis in children . . . . . . 469

— rheumatism in childhood . . . . 492

— rheumatoid arthritis . . , . . . 126

— septicaemia . . . . . . . . 505

— spine 547

— surgical tuberculosis 636

— ulcerative endocarditis . . . . 224

Bacteriuria, importance of isolating or-
ganisms in . . 658

,Bael fruit in sprue. . .. .. 547

Balanitis as cause of enuresis . . . . 228

Balsams in -gonorrheea, contraindications 270
Bananas in diabetes . . . . . . 203

Bandage for piles, fistula, etc. . . . , 700

— Ttvith plaster ends . , . . . . 6gi

— winder, new form of . . . . . . 691

Banti’s disease {see Splenomegaly) . . 544

P.\GK

Barium sulphate in hypertrichosis .. 295

meal in 2:-ray diagnosis . . . . 40

Basic fuchsin in chronic ulcers . . . . 647

Basket-handle operation for nephroptosis 313
Bastedo’s sign in diagnosis of appendicitis 1 1 8
Baths ill Graves* disease 264

— hot, in asthma of children . . . . 130

— , — bronchitis of children . . . . 164

— medicated, in psoriasis . . . , 464

— in prevention of tuberculosis in

childhood . . 628

— pemphigus foliaceus . . . . . . 428

— vapour, in rheumatoid arthritis . . 125.

Batten’s (Rayner) fixation fork for

operation for squint . . . . 557

Bayou’s culture in leprosy . . . . 334

Bazin’s disease, tuberculin in .. .. 512

Bed-bug as carrier of infection . . . . 674

— in etiology of parasitic thyroiditis , . 261

relapsing fever 542

— -pans, improvements in . . . . 722

Bedding manufacture, legal decision re . . 681

Beeves' parathyroid in tetany after

thyroidectomy 606

Behring’s diphtheria prophylactic . . 212

review of . . . . . . 81

Belladonna in asthma of children . . i3o>

— enuresis.. .. .. .. 328

— librositis . . 239

Bence-Jones’ proteinuria. . .. .. 462

Benzoate of mercury in syphilis . . . . 576

Benzoates, action of urine on . . . . 32

— in urinary infections 654

Benzoic acid as a urinary antiseptic . . 33

— and salicylic acid ointment in ring-

worm 497

Benzol, effect on metabolism in healthy

body ‘ 339-

— in leukaemia 337

Benzonaphthol ointment in psoriasis . . 464

Beri-heri, etiology and pathology . . 133,

— prophylaxis 135.

Besredka’s sensitized vaccines, relative

safety of 383

Benzold’s mastoiditis . . . . . . 404.

Bicarbonate of sodium in angina pectoris 114
witli salicylates in acute rheuma-
tism.. .. .. .. .. 491

Bicarbonates in pyelitis of diildren . , 474

Bier’s hyperacmia in alopecia areata . . 90

— — gbnorrheeal arthritis . . , . 269

rheumatoid arthritis . . . . 125

Bile-tract infection, urotropin in . . 12

Bilharzia associated with stone in Egypt 143

Biliary hyposecretion in children . . 214

— lithiasis in childhood . . . . . . 137

— obstruction after cliolecystostomy . . 138

Biliary tract, surgerj^ o’f . . . . 136

BiUington’s operation for movable kidney 314

Bisedia (liq. bismuth! sedatmis) 725.

Bismuth in amoebiasis . . . . . . 94

— and calomel in infantile diarrhoea . . 208

Bismuth gauze . . . . . . , . 725

— in intestinal dyspepsia of children , . 216

— and pancreatin, new preparation . . 725

Biodiemical tests of pregnancy . . . . 45^

Blackwater fever 138

Bladder, calculus cf 143

— contracture of neck of . . . . 146

Bladder, diseases of . . . . 139

— disorders, suggestion treatment in . . 366

— exclusion of, advantages and indica-

tions . . , . . . , . 145,

— paralysis, nerve-root anastomosis for 527

— rupture of 144

— simple solitary ulcer of . . . . 146

— symptoms simulating enlarged prostate 458

— tumours, operation for . . , . 140

I Blastomycosis, simulation of other diseases 147

GENERAL INDEX

XCl

Blastomycosis, vacdne-tlisrapy in
Bleeding in croupous pneumonia
Blistering in heart disease
Blood, Abdcrhalden’s dialysis test

— changes in infectious diseases

— dot dressing after mastoid operation

— coagulation, effect of ladio-active

substances on

— count in aleucocythsaemic leukaemia
chloroma . .

— : — dengue

diagnosis of typhoid fever

infantile infective anaemia

mumps . .

effect of radio-active substances

in otitis media

pellagra

relapsing fever

splenomegaly

tuberculosis

— cryoscop3^ in estimation of renal func-

tion . .

— culture in typhus

— ■ effect of colloidal copper on . .

iron on . .

tuberculin on

Blood, examination of . .

in cerebrospinal sypliilis . ,

diagnosis of scarlet fever . .

leala-azar

malaria

— injections in hajmorrhages of the

newly-bom . . ....

— occult, in diagnosis of cancer

— picture of cancer of bone-marrow and

pemidous aniemia

— platelets, origin of

Blood pressure . .

effect of pituitary extract on

tyramine of

high, and arteriosderosis . .

in nephritis . . . . ‘ .

rheumatoid arthritis

scarlet fever

thoradc aneurysm

treatment of hyperpiesis . .

— senim in diagnosis of cancer. .

— stream, bacilli in, in tuberculosis . .

— transfusion of dedbrinated, in severe

anmmia

in extra-uterine gestation

pellagra

— vessels, anastomosis of
Blue brain , .

Boiling-water injections in hyperthy-
roidism

Boils in ear, to abort raridly

— general and local treatment . .

— ichthyol for

— ionic 'medication in ..

— serum treatment of . .

— vaedne treatment of . .

Bone diseases, infectious, vaccine
therapy in . .

— formation in penis

-A marrow, carcinoma of, in relation to
pemidous anieniia

— marrow tabloids in pellagra . .

— transplantation for nasal deformity. .
Bones, metastatic nodules in, with

proteinuria . .

Bony conditions, A-ray diagnosis of
Books of the year . ^

Boradc acid in otitis media

as a urinary antiseptic

in urinary infections

— stardi poultices in eczema . .

B orated laic in moist dermatoses

page

Borax and glycerin mouth applications in

measles 363

Borcholin in tuberculosis . . . . . . 4

Bordet’s baciUus in treatment of p ertussis 433

Botryomycosis 154

Bougie, electric, in gonorrhoea . . . . 268

— in tinnitus 613

Bovine bacillus in etiology of surgical

tuberculosis 636

Bowels, regulation of, in asthma cf children 130-
Boyce’s ediper-guide for bronchoscopy 167
Bradycardia with lead colic . . . . 279

Brain, surgery of 155

— abscess of 155

due to amoebae . . , . . . q i

— extract for dementia .. .. 725

— fag, avoidance in spinal curvature . . 540

— injuries to, causing diabetes insipidus 200

— tumours ot, results of operation . . 156'

Bran baths in pemphigus fcliaceus . . 428

— in diet to prevent constipation . . 198

Branchial fistula, ionic medication in . . 59

Brass-workers’ itch and ague . . . . 686-

Breast, cancer of 160

modified operation for . . . . 162

radiotherapy in . . . . . . 'fr

vertebral tumours secondary to. . 520'

A'-rays in post-operative prophy-
laxis . . . . . . . . 46

— feeding, cotton-seed extract as aid in 7

— milk, estimate of. consumption of . . 29S

Brennemann’s experiments in curd forma-
tion 299

Bright’s disease {see Nephritis) . . . 373

Brui's disease, identity with t3rphus , . 647

Bromide of strontium in Graves’ disease 264
Bromides in arteriosderosis . . . . itz

— asthma of children 130

— daorea 495

— to diminish hypersecretion . . . . 503

— for insomnia during lactation . . 298

— in insomnia from eczema . . . . 220*

— phrenocardia . . . . . . , . 279

— thoracic aneurysm in

— tinnitus .. .. 613

Broncliial grlands, tuberculosis

of 162

— pus, excretion of urotropin in . . 13

— spasm, caffeine in . . . , . . 5

Bronchiectasis, anesthesia in operation

for 346

— bronchoscopy in . . . . ..170.

— solidification of lung in surgery of . . 348.

Bronchitis 164

— endo-bronchial treatment of . . .. 224

— erytliremia a bad sign in . . . . 453

— factors causing in stout people , . 166

— vaccine therapy in . . . . . . 165,

Bronchopneumonia, colloidal silver in . . 29.

Bronchoscope, direct applications through

in asthma and bronchitis . . 224

Bronchoscopy 166

— anaesthesia in .. .. .. .. 169

— indications for . . .. .. .. 170-

— in removal of foreign bodies . . . . 347

Bronchus, foreign bodies in . . . . 347

Broiiquet’s mask, to wear in treating

plague cases . . . . . . 439

Brown’s tuberculin B.F. Co 72^

Brytslele and asepsis of instruments , . 689

Bubo, climatic 171

Bucket and dilator in pyloric stenosis . . 475

Buerger’s urethroscope in gonorrhoea . . 267
Bulkley’s rice diet in eczema . . . . 220

Bullet wounds of abdomen . . . . 84

Bumam’s test for free formaldehj’dc in

urine . , . . . . . . lo*

in urinary infections . . . . 65s

Burns, ichthyol in , . .. .. .. 511

XCil

GENERAL INDEX

PACiE

Burns of the oesophagus . . . . 388

Burow’s tuberculosnti . . . . . . 72

Bursitis, subdeltoid .. .. 171

Buttermilk in gastrogenic diarrhoea . . 206

— treatment of erj^sipelas . . . . 231

Butliii’s operation for marginal resection

of tongue . . . . . . . . 614

Butyric test for albumin in cerebrospinal

fluid 189

pHARTERIS, E. J., i ; Collie, Sir J.,

^ 353 ; Coombs, C. F., 108, 114,

131, 130, 131, 133, 312, 224, 275*

278, 288, 439, 665

Cabinet (combination) for ward or surgery 692

— for ledger cards . . . . . . 692

Cacodylate of soda .in pellagra . . . . 418

Cacodylic add in psoriasis . . . . 465

Cade, oil of, in psoriasis . . . . , . 464

Ccesarean section in edampsta . . . . 457

indications and technique . . 324

Caffeine for headache during lactation . . 298

— pneumonia 443

— relieving bronchial spasm . . . . 5

Caisson disease 172

— etiology 172

pathology 173

treatment 174

Calamine lotion in lupus erythematosus 350
Calcinosis, multiple subcutane-
ous 174

Caldum chloride in heemorrhages of the

newly-bom . . . . . . . . 272

— lactate in tetany after thyroidectomy

264, 606

— s Its in epilepS5^ 229

Calculous anuria, surgical treatment . . 313

Calculus in EgsrPii inddence of . . . . 143

— renal 314

x-ray diagnosis of 44

— ureteral, oil injections for . . . . 650

— vesical 143

Caliper guide for use in bronchoscopy . . 167

— splint for fractured femur . . . . 245

Calomel and bismuth in infantile diarrheea 208

— in functional derangement of the liver 343

— intestinal dyspepsia of children . . 216

— ointment in psoriasis . . . . . . 465

— in phlyctenular conjunctivitis . . 195

— pyditis of children 472

— for stout bronchitics . . . . . . 166

Camphor, chloral, and menthol in hbrositis 338

— and lupulin in phrenocaxdia . . . , 279

— and picric add in ringworm . . . , 497

— therapeutic value of 3

Caucer 175

— Abdevlialden’s dialysis test in . . 150

— of anus 115

— arm, interscapulo-thoradc amputa-

rion for 93

— arsenical 119

— of the bladder. . . . . . . . 140

— bone-marrow and pemidous anaemia 98

— brain {see Brain, Surgery of) .. 155

— breast . . . . . . . . . . 160

Graves* disease secondary to . . 262

modified operation for . . . . 162

vertebral tumours secondary to . . 520

— colloidal copper in . . . . 7, 726

— of colon, diagnosis from diverticulitis 312

— a contraindicaiion for salvarsan . . 574

— curative action of metallic salts of . . 18

— diagnosis 175

— dissemination by grafting in operation 176

— of eyelid, radium in . . . . . . 233

— hospital, results of radiotherapy at . . 52

— interscapular thoradc amputation for 95
Cancer, laboratory diagnosis of tSo

— of larjmx, tedmique of operation . . 329

PAOE

Cancer, new methods of diagnosis . . 175

— of the ocsopliagus . . . . . . 385

surgical treatment . . . . 387

— patliology ty6

— of the prostate 461

— rectum, charts showing extension of 478

Kraske’s operation for .. .. 481

— radiotherapy in 5t

— skin 307

inoperable A*-rays in . . . . 513

mesothorium in 314

radiotherapy in 51

x-ray treatment in . . . . 47

— skin-reaction i75

— of spinal cord 319

— stomach 549

analysis of duodenal contents in 412

diagnosis of fibromatosis from . . 556

relation to ulcer 256

results of surgical operation . . 553

— tongue 614

— thryoid discovered on operation . . 607

— treatment 178

— of uterus . . . . . . . . 659

disappearance of glycosuria after

removal . . . . . . . . 203

radiation in . . . . . . 65

— x-ray treatment of . . . . . . 46

Cancerous stenosis of oesophagus, intuba-
tion in 170

Cantliaridin and geld combinations in

tuberculosis xi

Canvassing by friendly societies for

medical officers 670

Carbenzyme, action on necrosis, cyst

contents, etc ,6

Carbohydrate fever in children . . . . 2x5

— limitation in Graves’ disease. . . . 246

— metabolism, effect of pituitary

gland on 435

factors inflnendng . . . . 301

— restriction in functional derangement

of the liver 342

Carbolic add in eczema . . . . . . 220

tetanus 604

— lotion, method of applying in pedicu-

losis 415

— oil for throat in measles . . . . 363

Carbon dioxide snow in alopecia areata 90

arsenical cancer .. rrg

eczema 221

epithdioma of skin . . . . 507

lupus erythematosus . . . . 350

skin diseases 513

trachoma . . . . . . 233

Carbonate of ammonia for stout bron-
chitics 166

— magnesia in lupus erytliematosus . . 350

Carbundes, general and local treatment 254

— ichthyol for 51 1

-T- ionic medication in 59

— serum treatment of 29

— vaccine therapy in 36

Carcinoma {see Cancer)

Cardiac arrhythmia {see Auricular Fibril-
lation)

— disease, auricular flutter in . . . . 13?

relation of auricular fibrillation

to 130

in schoolboys 2 78

— failure, a terminal event of arterial

hypertension .. 153

— infantilism 379

— lesions, relation to spinal deformity 530

in rheumatism in diildhood . . 493

— malformation, congenital . . . . 212

— neuroses, neubomyval in . . . . 19

— rheumatism, treatment and after-care 282

— stimulant, camphor as a . . . . 5

GENERAL INDEX XCiii

PAGE PAGE

Cardiac stimulation in croupous pneu- Charcoal in intestinal dyspepsia of

luonia 442 children “ 216

— strain in anaesthesia 107 Cheilotomy for osteo-arthritis of hip

— symptoms of aneurysm . . . . 109 joint . 294

Cardiolysis in pericarditis . . . . 429 Chemistry of the blood 149

Cardio-pulmonary cases, polycytluemia Chemotherapy combined, experiments on 27

with 453 Chilblains, galvanic eurrent for . . .. 54

Cardiosclerosis and heart-block . . . . 2S8 Children, anaemia in 95

— sugar in treatment . . , . . . 283 — asthma in . . . . . . . . 128

Cardiospasm (Esophagus) .. .. 390 — backward, medical gymnastics for . ! 17

Carditis, otitis with . . . . . . 396 pineal gland extract for . , . . 434

— syphilitic (see Heart, Syphilis of) . . 275 — cardiac efficiency in 278

Carious teeth in etiology of gastric cancer 549 — diseases of , general review of . . .. 78

Carlsbad salts in functional derangement massage in 16

of the liver 343 — duodenal ulcer in 305

— Sprudel salt, imitation of . . . . 726 — errors of accommodation in . . ' . . 484

Cascara in arteriosclerosis . . , . 122 — fracture of neck of femur in . . . . 251

— infantile eczema .. 221 — gall-stones in .. .. ..137

Casein, precipitated, in infant feeding . . .301 — heart disease in 28 1

Castor oil in prophylaxis of arterio- — intestinal dyspepsia of (see Dyspepsia) 214

sclerosis 12 1 — jaundice in 30S

for stout bronchitics . . . . 1G6 — mechanical measures in bronchitis in 164

Casts passed during menstruation . . 366 — mentally deficient, legal decision re 6S2

— in urine, importence in diagnosis . . 658 — nephrohthotomy in . . , . . . 316

Catalepsy, suggestion treatment in . . 565 — pyelitis in . . . . . . . . 469

Catalysis, leptynol as stimulant of , . 15 — radical mastoid operation in. . . . 4111

Cataract 183 — rheumatoid arthritis in .. 123, 124

Cataract, patliology of .. 184 — rheumatism in.. .. .. 491

Catarrh of Eustachian tube . . . . 395 — rheumatic, special homes needed for 282

— nose and throat, vaccines in . . 383 — siphon drainage in empyema of . . 232

— fermentative intestinal, oxygen in- ' — syphilis in relation to deafness in . . 218

suffiation for 20 — tuberculosis in . . .. .. .. 623

— spring, radium in 233 Clitldren’s Act, operations xmder . . 671

Catarrhal jaundice in children .. .. 308 Chloasma, sulphur in 510

urotropin in i2 Cholin, borcliolin a non-toxic preparation

Catheterization in cancer of prostate .. 463 of . . ... 4

Catheters, _ formaldehyde in sterilization of 10 Chloral in chorea 495

— ureteric, shk web . , . . . . 692 — camphor, and menthol in fibrositis . . 238

(Cautery, in cancer of cervix uteri . . 661 — in insomnia from eczema . . . . 220

Cavernous angiomata, carbon dioxide — thoracic aneurysm iii

snow in 513 Chloride of ammonium inhalers, new

— sinus, thrombosis of 408 designs 703

Cell proliferants after mastoid operation 403 — -free diet in epilepsy 229

Cellulitis, colloidal iron in , . . . 14 Chlorine ionization in acute fibrositis . . 240

— vaccine therapy in . . . . . . ' 36 Chlormetacresol, an active antiseptic . . 6

Cdltdose, diet rich in, in prevention of Chloroform anaesthesia, causes of death

constipation . . . . , . 197 under . . . . . . . . 106

— intestinal digestion of 235 — belladonna and aconite in fibrositis 239

Central retinal artery, obstruction of . , 488 Chloroma . . . . . . . . . . 33^

Cereal gruels in infant feeding . . . . 301 Cholecystectomy in typhoid carriers . . 646

Cerebellar abscess, differentiation from Cholccystostomy, biliary obstruction after 13S

labyrinthitis , . . . . . 326 Cholecystitis, infective, early operation in 136

Cerebral lesions, relative to diabetes Choledocho-duodenostomy, indications for 137

insipidus . . . , . . . . 200 Cholelithiasis, analysis of duodenal con-

— tumours 155 tents in 412

results of operation . . . . 156 Cholesterin in anfemia in children . . 97

Cerebrospinal fever . . . . 186 — blood, significance of 149

diagnosis and treatment , . .. 187 — pathology of cataract . . .. .. 185

prophjdaxis 188 Cholera 191

symptoms . . . . . . . . 186 — epidemiology of . , . . . . 191

Cerebrospinal fiLuid . . . . 1S8 — treatment 192

biological and drug tests. . .. 190 Choleraic diseases, copper preparations in 7

cytology . . . . . . . . igo Chordee, aconite to diminish tendency to 267

examination in otitic meningitis 405 Chorea, clinical manifestations . . . . 493

in mumps . . . . . . . . 369 — salvarsan in . . . . . . . . 37

signs of syphilitic infection . . igo — treatment . . . . . . . . 495

— tests for albumin 189 Choroid, diseases of . . . 306

— syphilis .. .. .. ,. .. 586 Christian Science cures and auto-

luetin reaction in 571 suggestion 562

CereUes (containers for ointments and Chromafim system, relation to diabetes 302

soaps) 726 — tissues, degeneration caused by radio-

Cervical abscess , . . . . . . . 404 active substances . . . . , . 65

— glands, tubercifious, bo/n; xnd C 3 irysarobin in psoriasis . . .. .. 465

human bacilli in . . . . . . 636 — ringworm . . . . . . . . 497

Cervix uteri, amputation of, after- results 66 x Chylous cysts of mesentery .. .. 368

incidence of laceration of . . 323 Ciliary body, diseases of . . ^06

radiotherapy in cancer of . . 53 Cimex in etiology of parasitic thyroiditis 261

Chair, the " Grevillite ” folding . . 693 Cinchona alkaloid, amorphous, in malaria 353

Chalazion, radium in . . . . . . 233 Cirarlation, peripheral, stasis of . . 548

XCIV

GENERAL INDEX

PAGIS

Circumcision, tuberculosis due to .. 625

Cirrhosis of the liver . . . . . . 341

relation of spleen to . . . . 546

simulating splenic anoemia . . 545

— stomach (see Stomach, Fibromatosis of) 556

Citrate of potassium in cholera . . . , 194

in enuresis . . , . . . . . 228

pyelitis of children .. 472, 474

— sodium in non-traumatic detacliment

of retina 490

Citrate in urinary infections . . . . 654

Citrated milk in infant feeding . . . . 300

Citramine, action as urinary antiseptic. . 33

Clamps, new makes of 693

Clip for holding forceps, new design . . 694

Clothing in fibrositis 241

Coagulation time of blood . . . . 148

effect of radio-active substances

on . . . . . . 65

Coagulose, haemostatic ferment from

horse serum . . . . . . 726

Cocaine in pneumonia . . . . . . 443

Cocaine-adrenalin direct injections in,

asithma and bronchitis . . . . 224

Cocainism, suggestion treatment of , . 565

■Ciock's-comb test of ergot activity . . 9

Codeine, paracodin a substitute for . . 21

Cod-liver oil contraindicated in intestinal

dyspepsia in children . . . . 216

in convalescence from heart disease 282

infant feeding . . . . , . 302

phlyctenular conjunctivitis . . . 195

spinal curvature . . . . . . 540

tuberculosis in childhood. . .. 628

Colalin in functional derangement of

the liver 343

Cold, common, vaccine therapy in. . . 35

Coli bacilluria, vaccine therapy in . . 36

Colic, renal 315

Colitis, Abderhalden’s test in . . . . 152

— character of fasces in 236

— in children 214

— fermentative, oxj'gen insufSation for ’21

— ionic medication in. . . . . . . 59

— froxn pericolic membranes . . . . 431

— urotropin in . . . . . . . . 12

Collapse induration, diagnosis from

phthisis . . . . . . . . 629

— of lung, technique of causing, in

tuberculosis . . . . . . 445

in treatment of tuberculosis . . 345

Collargol enemata in flagellate dysentery 213

— injections in renal skiagraphy, errors

caused by 44

— therapeutic indications . . , . 29

CoUes's fracture, results of treatment . . 245

Colloidal copper in cancer . . 71, 80

— ^old chloride test for albumin . . 189

— iodine preparations . . . . . . 729

— iron in erysipelas and cellulitis , , 14

— mercurj' in funmculosis . . . . 254

— nitrogen excess in urine in cancer cases 18 1

— permanganate in cholera . . . . 192

— preparations of metals . . . . 726

— silver in hsemorrhagic syndrome of

infectious diseases .. 640

therapeutic indications . , , . 29

Collodion flexile in lupus erythematosus 350
CoUosals, colloidal preparations of metals 726
Coloc. c. hyoscy. pHl in arteriosclerosis 122
Colon, incarceration in lesser sac . . 304

— inflation in diagnosis of appendicitis 118

— late results of short-circuiting . . 303

— AT-rays and the surgical anatomy of . . 478

Coloptosis, etiology and treatment . . 667

Colostomy, inguinal, dressing for . , 304

— transverse, advantages of , . , . 303

Combined chemotherapy, experiments on 27
Comedo, acne bacillus as cause of . . 86

FACE

Complement fixation in diagnosis . . 623

gonorrhoea 264

Compression and decompression in

caisson .disease 172

— of spinal cord 519

Concussion of spinal cord .. .. 519

Congenital anomalies of the kidney . . 311

— asymmetry, malingerers and . . 357

— bilateral microtia 216

— heart malformation 212

— hypertrophic stenosis of pylorus,

jt-ray diagnosis of 40

— pyloric stenosis 474

— syphilis 597

and deafness 218

— torticollis 619

Conjunctiva, diseases of . . 194

— tuberculosis of . . . . . . 195

Conjunctivitis, hydrogen peroxide in . . 233

— infection in swimming-bath . . 196

— Parinaud’s 196

— phlyctenular . . . . . . . . 194

Constipation 197

— in aortic aneurysm, treatment . . iii

— children, massage in 16

— gastric cancer 549

— suggestion treatment in . . . . 566

Consimiption, pulmonarj% in Derbyshire

quarries 686

Continuous dilatation in urethral stric-
ture . . 652

Contraction ring, dystocia due to . . 335

Contractions, spastic, resection of nerve

roots for 525

Contracture of neck of bladder .. .. 146

— of prostatic orifice, operation for , . 461

Contr^uesin in syphilis 578

Copaiba in Chronic gleet 270

— psoriasis . . 464

Copper, colloidal, in cancer .. 7, 180, 726

— preparations in intestinal disorders .. 7

— salts in tuberculosis in childhood . . 628

— sulphate in mycetoma . . . . 369

Corbett’s test for amymolytic ferment

in urine . . . . . . . . 658

Cord-pressure signs in extramedullary

tumours .. .* .. .. 521

Cornea, diseases of 198

Cornea, scarlet red in lesions of , . . . 28

Corns, ionic medication for . . . . 59

— soft, carbon dioxide snow for . . 513

Corpora lutea, desiccated, for artificial

menopause . . 366

Cosmin, iodi decolorata . . . . . . 73 0

Costal cartilages, anesthesia in removal of 346
Cotton-cloth weavers, unusual form of

illness amongst 687

Cotton-seed extract for nursing mothers 7
Cong-h 199

— in diagnosis of thoracic aneurysm . . 109

— paracodin as a sedative in . . . . 21

Cracked nipples . . 297

Cranial injuries, relation to diabetes

insipidus . . . . . . . . 200

Craniotabes, relation to congenital syphilis 597
Cream cheese, cure of varicose ulcer by 648
Creeping exercises for lateral curvature r

of spine . . . . . . . . 531

Cresol in pemphigus folia ceus . . . . 428

— saponatiun in eczema. . . . . . 220

Cr^yl for fumigating malarial ships . . 352

Croias oil, tasteless castor oil preparation 726
Crotalin treatment of epilepsy .. .. 231

Croupous pneumonia . . . . . . 442

Crowe’s staphyloid coccus in rheumatoid

arthritis . . . . . . . . 126

Crucial ligaments of knee, rupture of . . 331

Cryoscopy of blood in estimation of renal

function 487

GENERAL INDEX

XCV

PAGE

Curd formation in boiled and unboiled

milk . . . . . . . . . . 299

Curettement of Eustachian tube in

chronic aural suppuration , . 400

after mastoid operation . . 403

Cupping in cholera . . . . . . 194

Cuprakrol, copper ointment for skin affec-
tions . . . . . . . . 726

Cuprammonium sulphate in cancer .. 180

Curette sharpener . . . . . . 694

Curvature of spine, treatment

by exercises 528

Cutaneous epithelioma, x-ray treatment of 47

— reaction in diagnosis of syphilis . . 570

Cyanide of gold and potassium in syphilis 581
Cycloform, co., ung., as emollient . . 726

Cymarin as a cardiac tonic . . . . 284

Cyst contents, action of carbenzyme on 6

— hydatid, of spinal cord . . , . 520

Cysts of bone, x-ray diagnosis of . . 43

— connected with hernial sacs . . . . 290

— of the liver . . , . . . . . 341

— mesentery 368

— ovarian, complicating, pregnancy, etc. 409

-7- of the spleen . . . . . . ..543

~ sebaceous, electrolysis in destruction of 513

Cystic hygroma of neck 373

Cystitis, hexal in 12

— of pregnancy 145

— relation of ^bumin to pus in . . 658

Cystopurin, action as urinaiy antiseptic 33
Cystoscopy in cancer of cervix uteri . . 659

— diagnosis of renal tuberculosis . . 318

— in dysuria in women 145

— importance with vesical tumour . . 140

Cystotomy, technique in cases of vesical

tumour r40

— in vesical calculus, advantages of . . 144

Cytology of blood examination . . . . r47

— cerebrospinal fluid 190

D acryocystitis 32S

“ D^mmerschlaf ’* with sacral

anaesthesia io8

Damming and percussion iu fractmre . . 244

Darier’s disease . . . . . . . . 310

Deafness {see Ear, Dise^es of) , . , . 216

— in children, relation of syphilis to . . 218

— middle-ear, as cause of vertigo . . 666

— from nerve degeneration . . . . 327

— simulated - . . . . . . . 218

Decapsulation of kidnej^s in eclampsia , . 457

Decompression operation for meningitis 405
Delirium tremens, aleudrin in . . . . 3

Dementia, brain extract in . . . , 72=5

— paralytica {see Syphilis, Cerebrospinal) 586
— nrfficox, Abderhalden’s test in .. 152

Dengue 199

— relation of sand-fly fever to . . . . 499

Deodorant, novitorm as a . . . . 19

— ozoline as a . . . . . . . . 730

— ozone as a .. 21

Depilatories in hypertrichosis . . . . 295

Depilatory effect of x-rays . . . . 50

Depression, aleudrin as sedative in . . 3

Dermatitis herpetifonnis, human blood
• injections in . . . . . . 512

— in pregnancy, serum treatment . . 457

— (traumatic) and eczema . . . . 223

Dermatogra, a symptom of pellagra 417, 426
Dermatol in eczema . . . . . . 221

Dermatology, general review of . . . . 79

Dermatoses, moist, dry treatment of . . 510

Desiccated corpora lutea for artificial

menopause.. 366

Dextrose in rectal feeding . . . , 483

Diabetes, Abderhalden’s dialysis test in 150
— amylolytic ferment test in . . . . 658

— analyst of duodenal contents in . . 412

PAGE

Diabetes, a cause of intermittent limp . , 122

— general review of . . . . . . 82

— Wassermann reaction in . . 204, 572

Diabetes insipidus 200

Diabetes mellitus .. .. 201

in early infancy . . . . , . 203

influence of alcohol on . . , . 203

radio-active substances contra-
indicated in . . . . . . 64

Diabetic asphj’xia, ox^’gen injections hi 21

— foods, new preparations of . . . . 727

Diabetics, operation for gangrene in . . 255

— operations on . . . . . . . . 205

Diachylon and plumbism . . . . 6S5

Diagnosis, tuberculin in . . . . . . 70

Dis^ostic value of gastric antiperistalsis 41
Dialysation method in diagnosis of

pregnancy 453

Dialysis blood test of Abderhalden .. 150

Diaphoresis in eye disease . . . . 233

Diarrhoea, copper preparations in . . 7

— false, character of faeces in . . . . 236

Diarrhoea of gastric origin . . 205
Diarrhoea, infantile .. .. 207

diet in 300

— suggestion treatment in . . . . 5^6

— value of uzura in . . . . . . 33

Diastase in faeces test for, in pancreatitis 411
Dictionary of materia medica and

therapeutics . . . . . . i

— of treatment 77

Diet in angina pectoris .. .. ., 114

— aortic aneurysm ' in

— arteriosclerosis 13 1

— and beri-beri . . . . . . . . 133

— in cirrhosis of the liver . . . . 341

— congenital pyloric stenosis . . . . 475

— diabetes 202

— eczema . . . . . . . . , . 220

— epilepsy 229

— etiology of pdlagra . . . . 420, 425

— functional derangement of the liver 342

— gastrogenic diarrhoea 206

— gout 270

— Graves’ disease . . . . 264

— heart disease . . . . . . . . 283

— hyperpiesis 154

— — iiifantile a'niyrnia . . . . . . 97

diarrheea . . . . . . . . 20S

— infants’ . . . . . . . . 297

— in intestinal dyspepsia in cliildreu . . 216

— jaundice in children . . . . . . 309

— nephritis . . . . . . . . 375

— nephrolithiasis. . . . . . . . 315

— prevention of constipation . . . , 197

— pyelitis of children . . , . . . 474

— rectal . . . . . . . . . . 483

— in rheumatoid arthritis .. ., 125

— for stout bronchitics . . . . . . 166

— in surgical tuberculosis . . . . 637

— treatment of pellagra . . 418, 427

— tuberculosis in cliildhood . . . . 628

— typhoid fever . . . . . . . . C43

Digalen, emetic and nauseant effect of . . 8

— new forms of , . . . . . , . 727

Digitalis in auricular fibrillation . . . . 1 3 1

— auricular flutter .. .. .. 132

Digestion, relative activity in intestines 235
Digestive S5Tnptoms of angina pectoris,

treatment .. .. .. .. 114

pellagra 417, 425

Digesto-laxative tabellse for chronic

dyspepsia . . . . . . . . 727

Digipuratum, emetic and nauseant effect of 8
Digitalin in angina pectoris . . . . 114

— tabloids . . . . . . . . 727

Digitalis in croupous pneumonia . . 442

— therapeutic action of . . . . . . 8

— — possibilities of .. ..283

xcvi

GENERAL INDEX

PAGE

Digitalis tincture, standardized , . .. 727

Digilalysatimi, emetic and iiauseant

effect of . . .... . . 8

Digitonin, removal from digitalis of . . 8

Digitoxin, diniination from tissues of . , 8

Dilatation, acute, of stomach . . . . 555

— continuous, in urethral stricture . . 652

— of Eustachian tube, method of . . 395

— stomach, post-operative . . . . 392

Dimethyl method of estimating blood-

serum alkalinity 176

Dioradin in surgical tuberculosis . . 8

Diphtheria 209

— antitoxins, revdew of . . . . . . 81

— Behring’s new prophylactic . . . . 21 1

— carriers, B. acidi lactici sprays in . . 21 1

staphylococcus sprays in. . . . 210

— colloidal silver in . . . . . . 30

— endotoxin, injections of .. .. 211

— and heart block 288

— otitis in . . . . . . . . , , 396

— stenosis of larjmx following . . . . 331

Diphtheritic ulceration, ionic medication

in 59

Diplosal (salicylo-salic3dic acid) . . ... 9

Diseases classed as accidents . . . . 6 yt

Dispensaries, tuberculin, growth ot . . 74

Disinfectant, alcoholic solution of iodine

as . . . . 14

— ozone of little value as . . . . 21

— value of formaldehyde as a . . . . 10

Disinfecting of skin, ’ alcoholic kaolin

paste in . . . . . . . . 14

— intestine, oxygen insufHation for . . 20

Dissecting aneurysm, cause of . . . . log

Disseminated ulcerative sporotrichosis 546
Diuresis in heart disease 285

— pituitary extract causing . . . . 200

Diuretic, hexal as a .. .. .. 12

— value of squill as . . . . . . 30

Diverticulitis, diagnosis . . . . 212

— of the sigmoid . . . . . . . . 303

Division of auditory nerve in tinnitus , . 613

Dixon’s tuberculin , . , , . . 71

Domen suspensory bandages . . . . 719

Douche for eye, new design . . . . 697

— tube, vaginal, new design . . . . 694

Douches in gonorrhceal arthritis , . . . 269

Dover’s powder in intestinal dj'spepsia

of diMren 216

Drainage of pericardial effusions . , 430

Drains and sewers, legal decision re . . 678

Dream analysis 563

Dressing boxes, glass, the “ Grevillite ” 694

— for head, adjustable 701

Dressings, formaldehyde in sterilization of 10

— improvements in sterilizers for . . 716

Dropsy, value of squill in . . . . 30

Drug habit, aleudrin in breaking patients

of . . . . . . , . . . 3

suggestion treatment of . . . . 563

Drjr cupping in cholera . . . , . . 194

— treatment of moist dermatoses . . 510

Ductless-gland extracts in Graves’ disease 264

anaemia in children . . . . 97

Ductus arteriosus, persistant . . 212
Dunbar’s pollen vaccine in hay fever . . 384

Duodenal pump for obtaining pancreatic

secretions 410

— stasis, ,r-ray diagnosis of . . . . 41

— tube for administering ipecacuanha , . 94

— ulcer, Abderhalden’s dialysis test in 152

in childhood . . , . . . 305

site of perforation of . . . . 550

.v-raj- diagnosis from gastric . . 238

Duodenitis, urotropin in . , . . , . i

Duodenum and stomach, sur-
gery of 550

intussusception of .. .. 555

Dural drain in otitic meningitis . . 406

Dysentery, amcehic . . . . 90

emetine as specific in . . 83, 91

— bacillary, vaccine therapy in . . 93

— colloidal silver in . . . . . . 30

Dysentery, flagellate . . • . 213

— uzura in duarrhoea of 33

Dysmenorrhcea, glanduovin in . . . . ii

— suggestion treatment in . . . . 566

— sjmthetic hydrastinin in . . . , 13

Dysmenorrhoeal membranes . . . . 366

Dyspepsia of angina pectoris, treatment 114

— chronic, digesto-laxative tabellm for 727

— fermentative, oxygen insufiiations for ao

— intestinal, character of fseces in . . 236

Dyspepsia (intestinal) of child-
ren 2r4

Ds^sphagia from oesophageal cancer . . 386

— thoracic aneurj'sm 109

Dj’spituitarism, classification of , . ,. 435

Dj^spnoea, bronchoscopy in , . . . 170

— in diagnosis of thoracic aneurj-sm , . 109

— starvation treatment of ^ . . . 166

Dystocia due to contraction ring . . 324

Dj^stopic kidney .. .. .. .. 31 1

Dj’strophia adiposogenitalis, pituitary

body and 433

Dwarfism, mitral 279

Dysuria in women 145

E ar, affections of, causing cough . . 199

in chloroma. . . . . . 33O

after salvarsan treatment . . 219

— catarrh of, diagnosis 217

Ear, diseases of . . ... . . ai6

— drums, spontaneous re-formation of 400
— functional and simulated affections of 318
— furunculosis of, rapid abortion . . 317

— pain in classification of . . . . 217

— polypi of 31 C)

Ear, syphilis of 218

Eclampsia 456

— amyloly tic-ferment test in . . . . 658

Ectopic pregnancy 455

Eczema 320

— association with occupations . . . . 322

— carbon dioxide snow in . . . . 513

— chronic pyogenic, vaccine-therapy in 511
— hmnan blood injections in . , . . 512

— in infants 221

— marginatum a form of ringworm . . 497

— new method of applying sulphur in . . 31

— oris syphlitica. . . . . . . . 397

— pdlidol in . , . . . . . . 22

— 2r-ray treatment .. .. 50, 513

Editor’s table 688

Education, legal decisions re . . . . 682

Educational vaccination stations . . 778

Egypt, cases of rhinoscleroina in . . 382

Einhom's duodenal tube for administer-
ing ipecacuanha , . . . , . 94

obtaining pancreatic secretions 410

Eiwei^milch in infantile diarrhoea . . 300

Elaterium in cirrhosis of the liver . . 341

Elbow, fractures at, results of treatment 245
Electrargol enemata in flagellate dysentery 213
— therapeutic indications ^9

Electric hot air in rheumatoid arthritis 126
Electrical methods in malignant disease
of nose . . , . . . . .

Electricity as aid to hypnotic treatment 5 Or
— in alopecia areata . . . . , . 90

— in suspected malingering , . . . 359

Electrocardiography in auricular flutter 132
— heirt-block . . . . . . . . 289

Electrolysis in li5’’pertrichosi3 . . . . 293

— bums of the cesojihagus . . , . 389

— destruction of sebaceous cysts . . 513

— rhinophyma 495

GENERAL INDEX

XCVU

PAGE 1

Electrolysis in titmitus . . . . . . 613

Electrophone, the “ Groos ” . . . . 695 j

Electro tlierapeutic 3 .. 38, 54 |

— in lumbago . . . . . . . . 240 ^

— simple solitary ulcer of bladder . . 147

— tinnitus.. .. .. .. .. 613

— vesical papillomata .. .. 141

Elepliantiasis 222

EUerman-Erlandsen test in tuberculosis 70 ;
Elixirs, new . . . . . . . . 727 i

Embolism of central retinal artery . . 488 i

— post-operative . . . . . . . . 392 |

Embryotomy in contraction ring . . 325 1

Emetic effect of digitalis bodies . . . . 8 i

Emetine . . . . . . - . . . 728

— in pidmonary haemorrhage . . . . 635

— as specific in amoebic dysentery S3, 91
Eminenagogue oils, small therapeutic

value of . . . . , . . . 9

Emphysema, anaesthesia in operation for 346

Emphysematous gangrene . . . . 254

Empyema 222

— anaesthesia in operation for . . . . 346

— in children, value of siphon treatment 222

— operation for . . . . . . . . 346

Encephalitis, haemorrhagic, after salvar-

san . . . . . . . . 26, 28

Endobronchial treatment . . 224

Endocarditis, infective, colloidal silver in 29

— obstruction of central retinal artery

in . . . . . . . . . . 4^^

Endocarditis, ulcerative (oriental 224

bacteriology . . . . . . 224

pathology . . . . . . . . 225

prognosis and treatment . . . . 227

symptoms . . . . . . . . 226

Endometritis, ionic medication in . . 59

Endosteal tumours, x-va.y diagnosis of . . 43

Endotlieliomata of spinal cord .. .. 521

Eneraata, nutrient . . . . . . 483

Enesol injections in psoriasis, value of . . 465

— in tabes 592

Entamoebae, varieties of . , . . . . 90

Enteric fever {see Typhoid)

Enteritis, Abderhalden’s test in . . 152

— in children . - . . . . . . 214

Enteroliths complicating .r-ray diagnosis 41
Enteroptosis, etiolo^ and treatmenc , . 667

Enucleation of tonsils in rheumatism in

childhood . . . . . . . . 494

Enules, epinine preparation in . . . . 72 S

Enuresis 22 s

— with pyelitis in children . . . . 472

— suggestion tre.T.tment hi . . . . 566

Eo.siuophilia characteristic of dengue . . 199

— with sporotrichosis . . . . . . 547

Epidemic pneumonia . . . . . . 443

— poliomyelitis . . . . . . . . 450

Epidemiology of cholera , . ^ . . . . 191

Epidermophyton inguinale m etiology of

ringworm . . . . . . . . 497

Epididymitis, gonorrliceal, vaccine ther-
apy in 33

— lecurreut, vasotomy for . . . . 504

Epidural hijections in enuresis . . . . 229

Epiglottic suture, modified instrument

• for 329

Epilepsy 229

— surgical treatment of.. .. 159, 230

— usually intractable to suggestion . . 564

Epileptics, thyroid deficiency in some . . 230

Epileptiform attacks with heart-block. . 288

Epinephrin {see Adrenalin)

Epiphyseal fracture of femoral head . . 251

Epith^oma (see Cancer)

Erasion and skin-grafting in arsenical

cancer .. .. .. .. 119

Ergot in enuresis 229

— Graves’ disease 264

PAGE

Ergot, qualitative tests of . . . . 9

Ergotoxin, cock’s-comb t^t of . . . . 9

Eruption of pellagra . . . . 417, 426

Eruptions, erj'thematous, in tj^phoid

fever ’ . . 639

Erj’sipelas, buttermilk treatment of . . 231

— colloidal iron in . . . . . . 14

— ichthyol in .. .. .. .. 511

— in infants, vaccine therapy in , . 34

— leucocyte extract in . . . . . . 15

— after mastoid operation . . . . 404

— removal of adenoids . . . . . . 88

— vaccine therapy in . . . . 36, 512

Erystj’pticin in uterine hEemorrhage . . 9

Efyfhema 231

ab igne . . . . . . . . 231

— complicating infectious diseases . , 232

— multiforme, vaccine therapy in . . 512

Erythema nodosum . . . . 232

Erythematous eruptions in typhoid fever 639
Ersrthraemia (polycythsemia) . . 452

Erythrocytosis megalosplenica . . . . 453

Ether anaesthesia, new appliances for . . 695

— in intravenous antesthesia . . . . 107

— and morphia in renal colic . . . . 315

— with nitrous oxide in major surgery ws

Ethmoiditis, suppurative, choice of opera-
tion for . . . . . . . . 371

Ethyl chloride freezing in epithelioma

of the skin. . . . . . . . 507

Ethylhydrocuprein in croupous pneu-
monia . . . . . . , . 442

Eucaine injections in sciatica . . . . 501

Eucalj’ptus oil in measles . . . . 363

Eustachian tube, catarrh of . . . • 395

curettement for chronic aural

suppuration . . . . . . 400

after mastoid operation . . 403

Exantliematic otitis . . . . . . 396

Exercise in fibrositis . . . . . . 241

— functional derangement of the liver 342

— heart-block . . . . . . . . 289

— importance in prophjdaxis of gout . . 271

— for stout bronchitics . . . . . . 166

Exercises, re-educative, in chorea . . 495

— in spinal curvature . . . . . . 32S

Exfoliative action of resorcin . . . . 507

salicjdic acid . . . . . . 50S

— dermatitis, dry method of treatment 51 1

Extension with operation for fracture . . 244

Exophthalmic goitre . - . . 262

Abderhalden’s test in . . . . 152

anaesthetic in operation on . . 609

the question of operation .. 607

radio-active substances contra-
indicated in . .' . . . . 64

radiotherapy beneficial in . . 54

role of thymus in . . . . . . 610

.r-rays in . . . . . . . . 606

Exophthalmos in chloroma . . , . 336

— often absent in Graves’ disease . . 263

Expectorant, “ mesbe ” as an . . . 18

Expectorants for stout bronchitics . . 166

Extracutaneous sporotrichosis . . . . 546

Extramedullary tumours of spinal cord 320
Extranasal operation for suppurative

ethmoiditis.. .. .. .. 371

Extra-uterine gestation 455

Extravertebral tumours of spinal cord . . 520

Eye affections in chloroma . . . . 336

— complications of leprosy . . . . 334

— diseases, general review of . . . . 82

— douche, new design , . . . . . 697

Eye, general therapeutics of . . 233

— instruments, pocket case of . . . . 6g7

Ej’eball enucleation, local anaestliesia

for : .. ..234

Eyelid retractor, new design . . . . 713

Eyes, artificial, the “ Eukoric . . . 697

GENERAL INDEX

xcviii

'pALTA, W., 6o ; French, H., 86, 98,
i 133, 127, 147, i54> 237, 241. 254,

260, 262, 270, 2S9, 334, 340, 434,

435, 452, 46S, 476, 490, 505, 544,

546, 348. 567, 611

Factor^’ and Workshop Act, decision
I under . . . . . . . . 679

Fseces, examination of .. .. 235

— in diagnosis of cancer. . . . . . 182

— diastase in, in pancreatic disease . . 41 1

— in gastrogenic diarrhoea . . . . 206

— importance of examination in amoebic

dysentery . . . . . . . . 91

— intestinal dyspepsia of children . . 215

— janndice in children . . . . . . 308

Familial dystrophy of hair and nails . . 274

— peniicious anaemia 98

Fat, abnormal distribution of . . . . 340

— digestion in intestine.. .. .. 235

— restriction in functional derangement

of the liver . . , . . . 342

in janndice in children . . . . 309

— splitting ratio in diagnosis of pan-

creatitis . . . . . . . . 413

Favus (see Ringworm)

— anchorion violaceum a new varietj’ of 497

Feeding of infants . , - . . . , . 297

general review of . . . . . . 78

Fehling’s test for albumin in cerebro-
spinal fluid . . . . , . . . 190

Femur, fractures of . . . . 244, 246

Ferments in blood, estimation of . . 149

— of the body, effects of thorium on . . 63

— urine, test for 658

Fermentation, intestinal, reaction of

faeces in . . . . . . . . 235

Fermentative dyspepsia and catarrh,

oxygen insufflation for . . . . 20

Ferrous iodide in rheumatoid arthritis. . 125

Fever, radio-active substances contra-
indicated in . . . . . . 64

fibrillation, auricular .. .. 130

Fibroid tumours of spinal cord . . . . 521

Fibroids, Caesarean section for . . . . 324

— danger increased with age in . . . . 661

Fibrolysin in fibrositis 238

— multiple subcutaneous calcinosis . . 175

Fibroma, nasopharyngeal, operation for 382
Fibromatosis of stomach. . . . . . 55 d

Fibromyomata of bladder, operation for 140
Fibrositis 237

— general and local treatment, . . . 238

— pathology and etiology . . . . 237

Filtration of -i:-rays, experiments in . . 45

Fingers, flexion of, from ischaemic myo-
sitis.. .. .. .. .. 370

I'inscn light disappointing in lupus ery-
thematosus 350

— - — results at the Dondon Hospital . . 54

Fistula after appendicitis, vaccine therapy 36

— novifonn in 20

— after perineal prostatectomy . . \ . . 652

Fits accompanying heart-block . . . . 289

Flagellate dysentery . . . . . 213

Flat-foot frequent with rheumatoid

arthritis \ . 124

Fleas as plague carriers . . . . 4.39

— typhoid carriers \ 674

Fhes in etiology of epidemic poliomyelitis\ 45 1

pumgxa . . . . ^ ^ \42x

— as porters of infection . . ^73

Flora, intestinal, influence on digestion ^6
Flour cure in diabetes ' . . 2^0

^ hjrpe^iesis ! .* iS'4
Fcet^ m^branes for skin-gr^thig

of antisyphiliSc treatoeiit ^ ^

Follicular processes, new method of :
applying sulphur in .. ..j. I

PAGE

Folliculitis, pustular, vaccine-therapy in 51 1
Fomentations in fibrositis . . . . 238

Food {see Diet)

— adulteration, legal decisions re . . <>77

— fever in children 215

— poisoning and infections, bacterial . . 673

uzura in diarrhoea of . . . . 33

— unsound, legal decision re warranty 684

Foot and mouth disease in man . , . . 241

Forceps, new designs in . . . . . . 697

— tonsil, new design . . . . . . 721

Foreign bodies in bronchi and lungs . . 347

thorax,^ x-ray localization of . . 168

Forensic medicine . . . . . . 670

Formaldehyde baths in keratodermia

blennorrhagica 310

as disinfectant for cotton-cloth

workers 687

— inhalants, improved . . . . . . 728

— in urine, Bumam’s test for . . . . 10

tests for 12, 655

— value as a disinfectant . . . . 10

Formalin-glycerin injection in empyema 224
Fowler’s solution in pellagra , . . . 418

Fractures 242

— femur . . . . . . . . 244, 246

— instrument for use in operation on 698

— leg bones 245

— massage and movements of joints after 17

— operative treatment of . . . . 246

— of ribs, indications for operation . . 347

— screw and screw-driver for operative

treatment of 7t5

— simple, report of B.M.A. Committee 24a

— of spine of tibia . . . . . . 321

— ulna 253

— upper limbs, results of treatment . . 245

— wrist 252

Framboesia, luetin reaction in . . . . 571

Franke’s operation for visceral crises . . 536

Freezing by ethyl chloride in epithelioma

of the skin . . . . . . 507

Freud’s psycho-analj^sis . . . . 466, 563

Fresh-air treatment of surgical tubercu-
losis.. .. .. .. .. 637

Friedmann’s claims for tuberculosis

vaccination . . . . . . . . 69

Friendly societies, canvassing for medical

officers by . . . . . . . . 670

Frostbite, ichthyol in srt

Fudbsin, basic, in chronic ulcers . . 647

Fudisine medicinal (Merck’s), in dirouic

ulcers . . . . . . . . 647

Fulguration in simple solitary ulcer of

bladder . . . . . . . . 147

Fumigator, the “ Cioiiin ” . . . , 698

Fungi, role of, in sprue . . . . . . 547

Fvmgus infections, new method of apply-
ing sulphur in . . . . , . 31

Furunculosis 354

— of the ear, rapid abortion . . . . 217

— ionic medication 59

— serum treatment of 29

— vaccine-therapy in .. .. 56, 511

G lendining, b., 102, 323, 365,

409, 453» 455, 498, 634, 659, 662,

664; Goodall, E. W., 186, 209,

232, 259, 363, 4x4. 443, 498, 499,

518, 638, 647, 664 ; Groves,

E. W. H., 155, 519 ; Gruner, O.,

147, 180, 188, 235, 343, 410, 411,

467, 547, 622, 656

Gall-bladder lesions, relation to spinal

deformity 530

simulating splenic angemia , . 545

— pain on percussion over, in typhoid
. fever . . . . . . ’ . . 640

A -7 removal in typhoid carriers . . . . 646

GENERAL INDEX

XCiX

PAGE

Gall-bladder, surgerv of . . . . . . 136

“ Galligen ” peritonitis without perfora-
tion of biliary tract . . . . 136

Gall-stones, analysis of duodenal con-
tents in 412

— in children . . . . . . . . 137

— A'-ray diagnosis of . . 39

Galvanic current for chilblains . . . . 54

Galvanized iron water pipes, poisoning

due to 673

Galvano-cautery in cancer of cervix uteri 661
Galvano-puncture in lupus erythematosus 350
Galyl, new arsenical compound, in syphilis 580
Ganglia in wrist in rheumatism in

childhood . . . . . . . . 493

Ganglionitis, acute posterior . . , . 294

Q-angrene 254

— complicating general infections . . 254

— opium in . . . . . . . . 20

— surgery of 254

Gamisheeitig of fees due to panel doctors 671
Gas bacillus infection . . . . . . 254

— in pleural cavity, method of introducing 445
Gasserian ganglion injection of alcohol

in trigeminal neuralgia . . . . 377

Gastein baths, nerve-stimulating effect of 65
Gastric antiperistalsis, diagnostic value of 41

— cancer . . . . . . . . . . 549

— disorders, Abderhalden's dialysis test in 152

in angina pectoris 114

relation to spinal deformity . . 530

suggestion treatment in . . . , 566

tests of duodenal contents in . . 412

;r-ray diagnosis of . . . . , . 40

— juice in diagnosis of cancer . . . . 180

Gastric ulcer 255

diagram of site of perforation . . 550

indications for gastro-enterostomy 551

pathology . . - 255

relation to cancer 549

symptoms .. .. .. .. 256

«-ray diagnosis of.. .. 41, 258

Gastro-enterostomy for cancer . . , . 552

— indications in ulcer cases . . . . 551

Gastro-intesthaal symptoms of pellagra

^ 4x7, 435

— treatment of phlyctenular conjuncti-

vitis 195

Gastrogenic diarrhoea 205

Gastroptosis, etiology and treatment . , 667

G^trostomy in bums of oesophagus . . 389

— for cancer of oesophagus . . 387, 554

Gaultheria applications in rheumatoid

arthritis . , . . . . . . 125

Gelatin baths in psoriasis , . . . 464

— in diet in typhoid fever . . . . 644

— injections in aneurj'sm . . , . 112

— pads in hsemorrhages of the newly-

bora.. .. .. .. .. 272

Gelatinized serum in hemorrhagic

syndrome of infectious diseases 640
General* paralysis {see Sj^philis, Cerebro-
spinal) . . . . . . . . 586

'Wassermann test in . . . . 572

new test of cerebrospinal fluid for 190

spirochaeta pallida in . . . . 569

Genital complaints, vesiculotomy for . . 504

— organs, relation of pineal gland to . . 434

pituitary body to . . . . 435

Genito-urinary mucous membranes,

anaesthetizing effect of potassium
permanganate on . . . . . . 22

— operations, spinal analgesia in . . -108

Gerhardt’s test for acetonuria, modifica-
tion of 657

Germicidal efiicacy of hydrogen peroxide

preparations . . . . , . 13

Gevser, for surgery . . . . . . 699

Giddiness, malingerers and . . . . 360

PAGE

Giles’ operation for displaced uterus . . 663

Gingivitis, salvarsan in 27

Glanders 258

Glands, softening, action of carbenzyme

on . . . . . . .... 6

— tuberciflosis, bovine and human

badlli in 636

— itr-rays preferred to operation on . . 48

Glandular extracts in anaemia in cliildren 97

Graves* disease . . . . , . 264

Glandular fever 259

Glanduovin (extractum ovariale), good

results of . . . . . . . . ix

Glaucoma 259

Gleet, chronic, treatment . . . . 270

Glioma of spinal cord . . . . . . 522

Glossina, r61e in transmittng tr3"pano-

somiasis . . , . . . . . 620

Gloves, formaldehyde in sterilization of 10

— sterilizing box for .. .. 71 S

Glucose in rectal feeding . . . . . . 483

— urine, test for . . .. .. 656

Glycerin and borax mouth applications

in measles 363

Glj'cerophosphates in fibrositis . . . . 2 38

— new combinations of . . , . . . TfeS

Glycogen in blood, estimation of .. 149

Glj'cogenic function of the liver 202, 203
Glycoheptonic acid, a carbohydrate for

diabetics . . . . . . . . 203

Glycosuria (see Diabetes Mellitus) . , 201

— cataract associated with . . . . 185

— increased by radio-active substances 64

— in tuberculous meningitis . . . . 365

Glycyl-tiy’ptophan test of cancer .. 180

Groifere, endemic 260

Goitre, exophthalmic . . . . 262

etiology and symptoms . . . . 262

the question of operation. . . . 263

— operation for . . . . . . . . 606

— tendency to, with rheumatoid arthritis 124

Gold chloride test for albumin .. 1S9

congenital sypliilis . . . . 190

— combinations in tuberculosis. . .. 11

— cj’anide and potassium in tuberculosis

of skin . . . . . , . . 315

Gonin fximigator . . . . . . . . 6g8

Gonococcal infection causing pericarditis 429

— lesions, value of vaccine therapy in 34, 36

Gonorrhoea 264

— in causation of iritis , . . . . . 306

— complement fixation test in . . . . 264

— heyal in . . . . . . . . 12

— ionic medication in , . . . . . 59

— kcratodermia blennorrhagica following 310

— treatment . . . . . . . , 266

— vaccine tlierapj' in . . . . . . 35

Gonorrhceal arthritis, treatment . . 26S

a variety of rheumatoid . . . . 127

— infections, chronic, phylacogen treat-

ment of . . . . . . . . 37

Gout 270

— acitrin as uric acid eliminant in . . i

— a cause of intermittent limp . . . . 122

— ionic medication in , . . . . . 59

— treatment hy thoriura-.r . . . . 66

Gouty processes, definite action of

thorium on 64

Granuloma, pupeudal . . . . . . 271

— telangiectodes . . . . . . . . 154

Grate, adjustable . . .. .. .. 699

Graves* disease (see Goitre, Exophthal-
mic, and Thyroid Gland Surgery)

Grevillite folding chair . . . . . . 693

— glass dressing boxes . . . . . . 694

Grey powder in infantile eczema . . 231

intestinal dyspepsia in children . . 216

Groos electrophone . . . . . . 695

Groves’ pegs in fractures 347

GENERAL INDEX

PAGE

Growth stimulation, thorium influencing 64
Grubler’s basic fuclisin in chronic ulcers 647
Guaiacol in advanced phthisis . . . . 634

— carbonate in rheumatoid arthritis . . 125

— in eye disease . . . . • . . . 233

Gumma of bone, ,r-ray diagnosis of . . 43

— brain, operation in . . . . . . 155

— carbon dioxide snow in . . . . 513

Gummatous meningitis, association with

diabetes insipidus 200

— sporotrichosis 546

Gunshot wounds of abdomen . . . . 84

heart 286

Guy’s pill in heart disease . . . . 282

Gyergyai’s dilator for Eustachian tube 395
Gjrmnastic treatment of spinal curvature 52S
Gymnastics, medical, for mentally

deficient children . . . . . . 17

Gynaecological operations, noviform in . . 19

Gynaecology, general review of . . . . 80

TLTOLLAND, C. T., 38 ; Hutchison, R.,
ii. 117, 197, 205, 212, 255, 341, 342,

344, 413, 483, 549 , 556, 605, 667
Habit-spasms, suggestion treatment for 565
Hemacytometer, Hayem-Sahli . . . . 700

Haemangiomata, mesothorium for . . 514

Haematinic serum in anaemia in children 97
Haemolysis in the production of infantile

anaemia . . . . . . . . 96

Haemoptysis in diagnosis of aneurysm . . log
phthisis . , . . . . . 631

— non-tuberculous, bronchoscopy in . . 170

Haemorrhage of the brain, operation for 158

— intrathoracic, as indication for opera-

tion 347

— pituitrin in arrest of . . . . 23

— pulmonary, emetine in . . . . 635

— suture in control of, method . . . . 567

— after tonsillectomy .. .. ,..619

— uterine, erystypticin in . . . . g

— vaginal, at menopause, importance

of education re . . . . . . 661

Hseiaorrhagres in the newly-

born 271

Haemorrhagic encephalitis after salvarsan

26, 28

— syndrome in typhoid fever . . . . 639

Hfemorrhoidal belt, new design . . . . 700

Haemorrhoids, ionic medication in . . 39

Hojmostatic, coagulose (from horse serum)

as a. . 726

Haemo-urochrome in diagnosis of cancer 181
Hair and nails, familial dys-
trophy of 274

Hair-ball in stomach, .r-ray diagnosis of 40
Hand deformity from ischemic myositfe 370

— test of malingerers for weakness of . . 356

— chlormetacresol in sterilization of . . 6

Handle, universal, for nasal punches, etc. 700
Harman’s director-forceps for laartial

tenotomj’ in squint . . . . 558

— ^new operation for squint . . . . 556

Hartel's method of injecting the Gasserian

ganglion 377

Hay fever, anovarthyroid serum in . . 3

pollen vaccine in . . . . 34, 384

Haynes’ operation for otitic meningitis

405, 407

Headache during lactation, analgesics for 298
Head dressing, adjustable . . . , 701

Hearing, degeneration of nerve of . . 327

— tests in prognosis of otitis media,

technique of 398

Heart and aorta, syphilis of . . 275
Heart block .288

— congenital malformation of . . . . 212

Heart, diseases of 278

associated with goitre . . . . 262

PAGE

Heart diseases and auricular fibrillation i3o>

auricular flutter in .. .. 131

in diildren . . 281

diagnosis of phthisis with . . 629

general review of 80

methods of investigation. . , . 280

pregnancy with, treatment . . 285

prognosis . . . . . . . . 280

in relation to pregnancy . . . . 281

spinal deformity . . . . 530

in rheumatism in diUdhood . . 493

treatment . . . . . . . - 282

— failure, a terminal event of arterial

hypertension 153

— inflammation, otitis with . . . . 396

— stimulation in croupous pneumonia . . 442

— symptoms of aneurysm . . . . 109

Heart, surg-ery of 286

Heat applications in fibrositis . . , . 239

gonorrhoea . . . . . . . . 268

— ■ erythema from application of . . 231

Heat exhaustion 289

— in treatment of sciatica . . . . 502

Hectine in syphilis .. .. 576, 579

Hediosite, a carbohydrate for diabetics 203
Helalin et pepsin co., liq.. hepatic stimu-
lant and protcid digestive .. 728

Heliotherapy in surgical tuberculosis . . 637

Helmitol, action as urinary disinfectant 33
Henoch’s purpura, serum treatment of 469
Hepatic abscess (see Liver)

— inadequacy in children .. .. 214

— lesions, relation to spinal deformity . . 530

Heredity in etiology of gastric cancer . . 549

— relation to psoriasis 464

— . in rheumatism in childhood . . . . 491

— and tuberculosis of childhood . . 624

Hermann-Perutz reaction in syphilis . . 572

Hernia 290

— “ en w SQi

— incarceration of part of colon in

lesser sac 304

— malingering in 362

Hernial sacs, formation of cysts in . . 290

Herpes gestationis, blood serum in . . 513

Herpes zoster 294

Herxheimer reaction in internal-ear

injuries . . . . . . . . 220

Hetol in tuberculous iritis .. ^ .. 234

Hetraline, action as urinary antiseptic . . 33

Hexal, a urinary antiseptic and sedative ib
Hexamethylenetetramine (see Urotropin)
High-frequency current in alopecia areata 90

in vesical papilloma .. .. 141

Hip joint, osteo-arthritis of • . 294
Hipposarcine Roy, a horse-muscle

preparation.. .. .. 7-39

Hollander’s method of rhinoplasty . . 49<)-

Horaosexualitj', psyclio therapy in . . 566

Hookw'omi disease (see Uncinariasis) . . 649

Hormonal in constipation . . . . 198

Horse serum in haemorrhages of the newly-

born , . . . . . . . 273

Horsford’s epiglottic suture forceps . . 329

Hot-air applications in tinnitus . . 613

Hour-glass stomach . . . . . , 555

Housing, Town Planning, etc,, .\ct, deci- r
,sions under . , . . . . 679

Human blood serum in Henoch’s purpura 469

haemorrhages of the newly-boni

272, 273

skin diseases 512

Hurtley’s test for acetonuria . . . . 656

Hydatid cyst of spinal cord . . . . 520

Hydrastinin, synthetic preparation of . . 13

Hydrobromic add in anteriosclerotic

vertigo , . , . . , . . . C 65

Hydrocarbon fermentation, reaction of

fseces in . . . . . . . . 235

GENERAL INDEX

PAGE

Hydrocephalus, internal, operation for. , 150

Hydrocliloric acid findings in gastric ulcer 257

gastrogenic diarrhoea , . . . 207

pellagra 418

tj’phoid fever diet. . . . . . 645

Hydrogen peroxide in cancer of oesophagus 38S

hypertricliosis . . . . ... 296

inflammations of the eye. . . . 233

preparations, germicidal efficacy of 13

Hydrolysis theory of cataract . . . . 1S4

Hydronephrosis, earl5' . . . . . . 319

Hydropathic establishments . . , . 767

Hydrophobia (see Rabies)

Hydrotherapy in pellagra . . . . 423

— syphilis . . , . . . . . . . 575

— tinnitus.. .. .. .. .. 613

Hydro thorax complicating cardiac disease 279
Hygroma, cystic, of neck . . . . 373

— tuberculous, action of carbenzyme on 6
Hyperglobulism, produced by radio-
active substances . . . . . 64

Hyperidrosis, sulphur in . . . . . . 509

H^’pemephronia, symptoms of . . . . 318

Hj'perpiesis {sec Blood-pressure)
Hj^permetropia . . . . . . . . 484

Hypertension, arterial, ,r-ray treatment 48
Hypertensive renal disease . . . . 374

Hypertonic saline in cholera . . . . 192

Hypertricliosis 295

— .r-ray treatment . . . . . . 50

Hyper- and hypopituitarism . . . . 433

Hypnotic, aleudrin as a 2

— luminal as a . , . . . . . . 16

— paracodin as a . . . . . . . . 21

HjiDnotics in eczema 220

Hypnotism {see Suggestion) . . . . 558

Hypodermic needles and syringes, new

designs 701

— syringes, improved sterilizer for . . 717

Hyp'ophosphites contraindicated in intes-
tinal dyspepsia in children . . 216

Hypophysin, depressor action of . . 23

Hypophysis cerebri {see Pituitary Body)
Hypospadias, penile, operation for . . 651

Hysterectomy with Caesarean section . . 324

— for fibroids and cancer, comparison

of results . . 66 z

— indications for. . . . , . . . 660

— vaginal clamp for . . . . . . 693

Hysteria, treatment by suggestion . . 564

Hysteropexy for displacement of uterus 663
Hysterotomy in pernicious vomiting . . 456

TCHTHYOL in eczema .. .. 221

JL — hipus erythematosus . . . . 350

— pain in post-operative thrombophle-

bitis. . 394

— skin diseases .. .. .. .. 511

Ichthyosis {sec Keratosis)

— ichthyol baths in 511

Ileal kink, r-ray diagnosis of . . . . 41

Immunization in tuberculin treatment.. 68
Impetigo contagiosa, vaccine- therapy in 511

— new method of appljung sulphur in 31

Incandescent light in atonic wounds . . 55

Incarceration of colon in lesser sac . . 304

incision of skin, spiral, for varices , . 665

Inclusion bodies in diagnosis of scarlet

fever 500

Incontinence of urine in women . . . . 654

India, liver abscess in 91

Indigo carmine test of renal sufficiency . . 487

Industrial diseases and toxic-

olo&y 685

Inebriates, institutions for . . , . 765

Infancy, arterial pressure in . . . . 153

— diabetes inellitus in 203

Infant, effect of antisyphilitic treatment

of pregnant mother on . . . . 584

PACE

Infant feeding: 297

general review of . . . . , . 78

rules for . . . . . . . . 299

— mortalit5% influence of sj'philis on . . 597

Infantile anaemia (see Anaemia)

Infantile diarrhoea 207

“ ciweissmilch ” in . . . . 300

— sexual trauma in production of

neurose.s . . . . . . . . 466

— splenomegaly, .r-ray treatment of . . 48

Infantilism, cardiac . . . . . . 279

Infants, eczema in .. .. 221

— rules for artificial feeding of . . . . 299

— strangulated hernia . . . . . . 290

Infarction of kidney . . . . . . 319

Infections, acute, hEemorrhagic condi-
tions in . . . . ' . , . . 639

heart block with , . . . . . 2S8

— bacterial of food 673

— following operations .. ., .. 391

removal of adenoids .. .. 88

— gangrene complicating . . . . 254

Infectious diseases, erythema complicating 232

general review of . . . . . . Sr

otitis media following . . . , ^96

silver arsenite in . . . . . . 4

Infective diolecystitis, early operation in 136
Influenza bacillus, associated with ulcera-
tive endocarditis . . . . . . 225

— phthisis wrongly described as . . 630

Infusion apparatus, new design. . .. 703

Inguinal colostomy, dressing for . . 304

Inhalation anaesthesia 102

Inhalants, formaldehyde, in lung and

throat affections . . . . . . 728

Inhalers, new designs of . . . . 696, 703

Injection treatment in sciatica . . . . 501

Innominate artery, aneurysm of .. 112

Inoculation non-effective in prophjdaxis

of pneumonic plague . . . . 438

Insanity 366

— Abderhalden‘s dialysis test in 150. 152

— brain extract in . . , . . . 725

Insect porters of bacterial infections . . 673

Insects as carriers of kala-azar , . . . 331

— in etiology of pellagra .. .. 421

Insomnia in aortic aneurysm, treatment in

— aleudrin in . . 7 . , . . . 2

— from eczema . . . . . . . . 220

— during lactation, sedatives for . . 29S

— luminal in . . . . . . . . 16

— nervous, ureabromine in . . . . 32

. — paracodin in . . . . . . . . 2t

’ — suggestion treatment in . . . . 566

Institutions for inebriates . . . . 765

— mental treatment . . . . . . 752

— nursmg . . . . . . . . . . 7C8

Instrument cases, improved pocket . . 712

Tnslrumenls, appliances, etc., wanted . . 795

— formaldehyde in sterilization ot . . 10

— improved 'sterilizers for . . . . 717

— new methods of sterilizing . . . . 689

Insufflation method in control of open

pneumothorax . . . . . . 346

Insurance Act, garnish eeing of fees due

to doctors under . . . . . . C71

legal decisions under . . . . 680

liatjility of panel doctor under . . 670

— offices, index to . . . . . . 797

— relation of albuminuria to . . . . 88

Intercostal nerves, avulsion for visceral

crises .. .. .. .. 526

Intermittent limp, causative factors of. . 122

Internal organs, suggestion in functional

disorders' of . . . . . . 566

International Pneumothorax Association 445

Interscapulo-thoracic amputations . . 95

Interstitial keratitis, salvarsan in . . 198

— pancreatitis, diastase in urine in . . 41 1

GENERAL INDEX

czi

PAGE PAGE

Interstitial parotitis 414 Iodine, nascent, in phthisis . . . . 6^5

Intertrigo, pcllidol in 22 — in plague 440

Intestinal antiseptics in Graves’ disease 264 — ointment, non-staining .. .. 726

value in goitre . . . . . . 262 — ringworm . . . . . . . , 497

— contractions," eilcct of pituitary ,ex- — simple goitre . . 606

tract on . . .. .. ..23 — tinnitus.. .. 613

— crushing clamp, new design . . . . G93 lodipin in arteriosclerosis , . . . 122

— disinfectant, oxygen insi&ation as . . 20 — fibrositis .. .. ., 238

— disorders, character of faeces in . . 236 Iodoform, noviform a new substitute for 19

copper preparations in . . . . 7 lodoglidine in arteriosclerosis . , . . 122

suggestion treatment in . . . . 566 Ionic medication 55

— dyspepsia of children {see Ds^spepsia) 214 in fibrositis . . . . . . 239

— indigestion of infants, precipitated herpes zoster . . . . . . 294

casein in .. .. .. 301 lupus erythematosus .. .. 350

— infections, colloidal silver in.. .. 30 methods of application . . . . 58

— intoxication as cause of arterio- tables of dosage in . . . . 57

sclerosis . . . . . , . . 122 Ipecacuanha, administration through

— lesions, relation to spinal deformity . . 530 duodenal tube .. .. .. 94

— obstruction, diagnosis of pancreatitis — and emetine compared in amoebiasis 91

from.. .. .. .. .. 413 — in sprue 547

bj? gall-stones . . , . . . 137 Iridin in functional derangement of tlie

— parasites in appendix . . .. .. 116 Ih’er 343

— stasis complicating appendicitis .. 116 Iridocyclitis, guaiacol diaphoresis in .. 234

■ and putrefaction in causation of Iris, ciliary Ibody, and choroid,

c diabetes, etc. 204 diseases of 306

AT-ray diagnosis of . , . . 41 Iritis, tuberculous, hetol in . . . . 234

Intestinal surgery 302 Iron in aneeniia in children . . . . 97

Intestinal ulceration in children 305 — blood 149

Intestine, large, late results of short- — colloidal, in erysipelas and cdlulHis . . 14

circuiting 303 — -in eczema 220

Intestines, gimshot wounds of .. .. 84 — pellagra 427

— relative activity of digestion in . . 235 — perchloride in ringworm . . . . 498

Intralaryngeal inspection, epiglottic Irrigators, improvements in . . . . 705

suture for 329 Irritable conditions of throat, thymacetol

Intramedullary tumours of spinal cord. . 520 in 31

Intranasal operation for suppurative Ischannic myositis (see Myositis) 308, 369

ethmoiditis 371 Isoamylamine hydrochloride, coCk’s-

Intrathoracic aneurysm Aneurysm) comb test of 9

Intratracheal anaesthesia . . ' .. 104 Isopral in intravenous anaesthesia .. 107

for spinal surgery . . . . . . 524 Itch {see Pruritus)

— insufflation, apparatus for . . . . 695

Intravenous anaesthesia 107 TACKSONIAN epilepsy, operation for

Intravertebral tumours of spinal cord . . 520 J 159, 230

Intubation in inoperative cancerous O'aundice in children . . . . 308

stenosis of oesophagus . . . . 170 — acute infectious 309

Intussusception caused by diverticulum 302 — ■ catarrhal, urotropin in .. .. 13

— ^ resection of part of colon for . . .. 302 — with malaria-like fever ,. .. 353

— of stomach and duodenimi . . . . 555 — in relation to pernicious ancemia . . 99

Invalid lifter and support, new designs. . 704 Jejunum, accessory pancreas in. . . . 412

Invalids, homes for . . . . " . . 768 Jianu’s operation in cesopliageal cancer 3S7

iodeor^uii^ 'isdargol; colloidal iodine Joachimslhal baths, iierve-stimnlaling

preparations * .. ‘ " .. 729 effect of 65

Iodide of iron in rheumatoid artliritis . . 125 Joha {see Salvarsan) . . . . . . 37

— mercury in lupus erythematosus . . 350 Joint affections, rheumatic, radiation in 66

— potassium in angina pectoiis .. 114 — effusions, massage to remove iG

aoriic aneur3?sm in Joints, inflammation of, otitis with . . 396

arteriosclerotic vertigo . . , . 666 — complete rest, in rheumatoid arthritis 124 .

asthma of children . . . . 130 — stiff and painful, malingerers and . . 355

congenital syphilis , . . . 582 Jugular bulb, diagnosis of thrombosis of 407

excretion by kidneys of . , . . 487

in fibrositis 238 T/ ALA-AZAB. . , . . ‘ . 331

mycetoma . . . . . . . , 369 IV — identity ^ of infantile infective

psoriasis . . . . . . . . 464 anaemia with . , . . . . 96

sporotrichosis . . . . . . 547 Kaolin in disinfection of skin . . . . 14

syphilis of the liver . . . . 344 Kaplan’s test for albumin in cerebro-

syphilitic arthritis . . 128 spinal fluid ^ 189

heart disease . . . . . . 277 Karell diet in heart disease . . . . 285'

Iodides in arteriosdierosis . . . . 122 Kelly’s apparatus for intratracheal auses-

lodine, alcoholic solution of, as skin thesia . . , . . . . . 104

disinfectant . . . . . , 14 Kepler malt extract 729

— in artificial limp 122 Keratitis, developing from phlyctenular

— capsules for first dressing , . . , 729 conjunctivitis 194

— cholera 192 — hydrogen peroxide in 333

— endemic anaatnia of children . . . . 97 — interstitial, salvarsan in . . . . 198

— fibrositis . . . . . . . . 239 — non-ulcerative, guaiacol diaphoresis in 234

— infantile diarrhoea 207 Keratodermia ‘blennorrliagica . . 310

— injections in salpingitis . , . . 498 Keratosis follicularis . . . . 310

— lotion in sporotrichosis .. .. 547 — ichthyol baths in 511

— in mycetoma . . . . . . • . 369 — of the lips, seborrhceic . . . . 341

GENERAL INDEX

PAGE PAGE

Keiion, ichth3’ol in 511 Lane’s plates in fractures .. .. 246

Kemig’s sign in cerebrospinal fever . . 186 instrument for use in adjusting 698

Kerol, a diphens'l derivative, as intestinal Lange’s test in cerebrospinal fluid . , 189

antiseptic .. .. .. .. 729 sj'philis .. .. 573

Khartoum, anti-malarial work at . . 352 Lar\nigeal affections, fonnaldehj'de inha-

Kidney, acute haematogenous infection of 319 "lants in 72 S

— calculi in . . . . . . . . 314 — inspection, epiglottic suture for . . 329

— congenital anomalies of .. .. 311 — ners^e paralysis from goitre .. .. 606

— decapsulation in eclampsia . . . . 457 superior, division in larjmgeal

— disease, Abderhalden’s dial3rsis test in 150 tuberculosis .. .. 331

chemistpy of blood in .. .. 149 — paralj’sis .. .. .. 331

x-ray diagnosis of.. .. .. 44 — > symptoms of aneurysm .. 109, no

— dumb-bell .. .. .. .. 313 — tuberculosis, artificial pneumothorax in 44 S

— effect of salvarsan on . . . - . . 27 Laryngitis stridulosa, diagnosis from

— efficiency tests (see Renal Efficiency) 483 asthma . . . . . . . . 139

— gunshot wounds of . . . . . . 85 Laryngoscopic apparatus, improvements

— horseshoe 312 in 706

— incision for suppression of urine in Laryngoscopy, suspension . . . . 326

black-water fever . . . . . . 139 Larynx . . . . . . . . . . 328

— lesions, relation to spinal deformity 530 — cancer of . . . . . . . . 339

— movable ••33:3 — radiography of 328

operations for , . . . • • 313 — salvarsan in ulcerations of . . . . 384

— post-operative infection of . . . . 331 Lasophos, a new nerve tonic . . . . 729

— pseudo-calculus of . . . . . . 44 L^sar’s paste in lupus erythematosus . . 350

— relation to senile cataract . . . . 1S5 lateral sinus thrombosis. . . . . . ^07

— removal of, for pyelitis in childhood. . 474 lavage in congenital pyloric stenosis . . 475

— results of operations on . . . . 319 Laxatives in angina pectoris . . .. 114

Kidney, surgrery of . . . . 3x1 Lavatorj’^ disinfection, apparatus for . . 7x2

— suture of . . . . . . . . 330 Lead colic, bradycardia with . . . . 279

— tuberculosis of . . . . . . 3x7 — in eczema 220

dysuria in ' . . 145 — lotion in psoriasis 465

— tumours of . . . . . . , . 3x8 — • poisoning by diachylon . . . . 685

Killian’s suspension laryngoscopy . . 328 Lather-bottle stomach . . . . . . 556

Knee, injuries to 321 Leeches for stout bronchitics .. .. x66

— jerks in cerebrospinal syphilis . . 587 Leg bones, fractures of 345

— joints, oedema of, in rheumatoid — cradle, new design . . . . . . 706

arthritis 124 Legal decisions 677

Knife, Bruning’s guarded ,. .. 705 Legal’s test for acetonuria, modification of 657

Kobelt’s electric bougies in gonorrhoea . . 268 Leislimaniasis 33i

Kopetzky’s test in prognosis of meningitis 404 — failure of x-tay treatment in . . . . 48

Kraske’s operation for cancer of rectrun 481 Lens (see Cataract) . . 183

Kreuznach baths, nerve-stimulating I^enigallol in eczema . . . . . . 220

effect of 65 L^rolin injections in leprosy . . . . 334

Leprosy, bacteriology and treatment 333

L ANGMEAD, F., 95, 207, 314, 22S, — bacillus, action of radium on .. 33

272, 297, 30$, 308, 394. 4x4, 433, — surgerj’- of 334

469, 474, 491, 503, 597, 619, 623, — universal segregation advised . . 334

648 ; Leech, P., 94, 112, 119, 160, Leptynol for reducing adiposity. , . . 15

171, 223, 242, 254, 286, 294, 322, Lerche’s oesophagometer in cardiospasm 390

344» 373, 39i> 428, 496, 517, 527, Leucocyte coimt in otitis media, . . . 396

541, 567, 605, 614, 636, 665; effect of radio-active substances on 64

Little, E. G., 83, 86, 89, 1x9, 174, — extract in erysipelas . . . . . . 15

220, 231, 232, 254, 274, 294, 205, Leucoc3*tes, effect of tuberculin oil . . 75

31a, 340, 341, 349, 369, 415, 427, Leucocytosis in acute parotitis .. 415

464, 495, 496, 503, 307, 515. 647, — dengue 199

659 — herpes zoster .. .. .. 294

Laboratory tests of pregnancy . . .. 433 — not always present in leukaemia . . 336

Labour 323 — in relation to typhoid fever . . . . 641

— obstructed 324 — tuberculosis 623

— ovarian tumours complicating . . 409 Leucocytozoon syphilis . . . . . . 569

— sequelae of 323 Leukaemia 334

I,ab>’Tinthine disease and vertigo . . 666 — analogy of polycytliiemia to . . . . 453

Labyriutkitis 325 — diagnosis 335

Lacrymal apparatus, diseases — experimental 334

of .. . . .. .. .. 327 — myeloid, A'-ray treatment of .. 47

— secretion as test in anaesthesia . . 106 — nodular. . . . . . . . . . 336

ivactation, difficulties in commencement of 297 — treatment . . . . . . . . 337

Lactagol for nursing mothers . . . . 7 — thorium-z in . . . . . . . . 67

Lacteol, a new lactic ferment . . . . 729 — witliout leucocytosis . . . . . . 336

Lactic acid in diabetes . , . . . . 204 Leuksemic eruptions of tke skin 340

infantile diarrhoea . . . . 208 Lewisohn’s telescopic oesophagoscope . , 171

Lacto-bacillin in infantile eczema . . 221 Libido, sexual, in production of neuroses 466

Lacto-vegetarian diet in angina pectoris 1x4 Lice in etiology of relapsing fever ^ . . 542

Lactose, excretion by kidneys of .. 487 Lichen planus, human blood injections iu 512

Lagophthalmus complicating leprosy .. 334 Lienlery of children, opium for . . .. 216

Lamblia intestinalis as enuse of dysentery 213 Life insurance offices, index to . . . , 797

Lamps, electric head, new designs 705, 706 relation of albuminuria to . . 88

Laud unfenced, legal decision re . . .. 684 Ligaments of knee, rupture of .. .. 321

Lane’s ileal kink, -r-ray diagnosis of . . 41 Ligature cases and bottles, new designs 707

CIV

GENERAL INDEX

PAGE

Light in etiology'- of pellagra .. 430, 424

— " Ire.'ilniciil . . . . . . , , 54

Jaghtuiiig pains relievccl by salvarsan . . 502

Ligacous'phlcguion of abdoitiitial wall . . S5
Litiitw plastica (see {istomacli, Pibroiuatosis

of)

Linseed baths in pemphigus foHaccus . . 428

Lipase in duodenal contents in pancrmtic

and gastric diseases .. 411,412

IiipodystropMa progressiTra . . 340
Lips, seborrhoeic keratosis of.. 341
Liq. ferri perchlor. in ringworm . . . . 498

Liquorice powder in arteriosclerosis . . 122

Lithotomy, indications for , , . . 143

Lithotrity the operation of choice in

Egypt 143

Litholapax:y, advantages of . . . . 143

lyime salts in oxalic acid poisoning . . 20

Liver, a'bscess of {see Amoebiasis) . . 90

— conditions causing intestinal dyspep-
sia in children - . . . . . 214

Liver, cirrhosis of 34*

relation of spleen to . . . . 546

simulating splenic aiiannia .. 545

Liver, cysts of 341

—•lesions, relation to spinal deformity . . 530

a!-ray diagnosis of . . .. .. 30

Liver, functional derangement 342
Liver, functional efficiency, tests

for 343

— gunshot wounds of 85

— relation to diabetes mellitus. . . . 201

Liver, syphilis of 344

Lobelia in asthma of children . . . . 130

Local anaesthesia in sciatica . . . . 501

— and regional anaesthesia .. .. 108

Locomotor ataxy {see Syphilis, Cerebro-
spinal)

aleudrin in pains of . . . . 3

Lourdes cures, auto-suggestion and . . 562

Ludyl, new arsenical compound, in

syphilis . . . . 580

Luetin reaction in diagnosis of syphilis 570

Lumbago {see Fibx'ositis) 237

Lumbar puncture in enuresis . . . . 229

otitic meningitis . . . . 404, 405

sciatica 501

traumatic epilepsy . . . . 230

Luminal as a sedative and hypnotic . , 16

Luminotherapy in atonic wounds, etc.. . 55

Lung, abscess of , . . . . . . . 347

— affections, treatment by collapse . . 345

— conditions, obscure, A'-ray diagnosis in 42

— foreii^ bodies in 347

— impaired resonance over, in typhoid

fever 640

— infections after removal of adenoids 88

— inflammation of, otitis with . . . . 396

— injuries of, indications for operation 347

— lesions from umbilical infections . . 64S

— method of causing collapse of, in

tuberculosis . . . . . . 445

— penetrating wounds of, treatment . . 348

— site of primary lesion in tuberculosis

of childhood . . . . . . 623

— solidification, methods of producing 34S

Lungr, surgery of 344

LupuUn and camphor in phreuocardia . . 279

Lupus erythematosus .. .. 349

carbon dioxide snow in . . . . 513

mesothorium in 514

suprarenal extract in .. .. 515

— Finsen light in . . . . . . . , 54

— gold cyanide, potassium, and tubercu-

lin in . . , . . . . 516

— ionic medication in . . . . . . 59

— “ mesbe ’* in treatment of . , . . 18

— nasi, nascent iodine in . . . . 382

— vulgaris, carbon dioxide freezing in . . 5x3

TAOE

Lupus vulg.iris, vaccine- therapy in .. 512

lyvnipangioplasiy in elephantiasis . . 222

Lymphatic gland extract in adenoid cases 88

tablets for adenoids and enlarged

tonsils . . . . , . . . 729

Lymphatic glands enlarged, with rheu-
matoid arthritis 124

site of primary lesion in tuberen-

losis of diildhood . . . . 625

— and splcnomednllary leukajmias,

inter-relationship . . . . . . 335

Lymphocytes, to distinguish from myelo-
blasts 335

Lymphocytosis in acute parotitis . . 415

— diagnostic significance of . . . . 148

Lymphosarcoma, radiotherapy in . . 53

M arshall, c. f., 264, 568 ; Mon-

serrat, K. W., 175 ; Moynihan,

SirB. M. G., 84, 85, 115, 136, 290,

303, 34L 368. 412, 430, 432, 543,

550

Mherogeuitosomia, effect of pineal gland

on 435

Magnesium carbonate in lupus erj'thema-

tosus . . . . . . . . 350

— sulpjhate in flagellate dysentery . . 213

injections in eclampsia . . . . 457

in tetanus . . . . . . 599, 604

Magnifier, “ third hand^' . . . . 707

Maize, diet in etiology of pellagra 418, 424

Malaria 350

— with marked jaundice . . . . 353

— pernicious 353

Malarial ausemia . . . . . . . . 353

— parasite, cultivation of .. .. 351

IVIalignaxit disease of nose, electrical

methods in 382

colloidal copper in . . . . 7

rapid growth after exposure to

radium . . . . . . . . 38

ar-ray treatment of . . . . 46

Malingering 353

— conduct of medical witness in court 358

— and congenital sjnnmetry . . , . 357

— deafness .. .. .. .. 318

— examination of hack in . . . . 358

— general conduct of examination .. 35.4

— giddiness and neurasthenia . . . . 358

— in hernia . . . . . . . . 362

— and loss of sensation.. 358, 361

— necessity for detection of . . ' . . 353

— and sciatica . , . . , . . , 357

— in skin disease. . . . . . , . siu

— stiff and painful joints . . , . 355

Malnutrition in children, massage in . . '16

— in etiology of plilyctenular conjuncti-
vitis 194

— with spinal curvature, treatment . . 540

Malt extract in infant feeding . . , . 302

— and olive-oil cream . . . . . . 736

Malta Fever 363

IMaltine in intestinal dyspepsia of children 216
Manganese toxicosis, symptoms and

treatment 687

Manometer, use of, in artificial pneumo-
thorax 44JS,

Marfan's method of puncture in peri-
carditis .. .. .. .. 429

IMarmorek’s serum in tuberculosis . . 70

Marriage, when contraindicated in heart

disease 2S3

Marrow in production of Bence-Jones

proteinuria . . . . , . 464

Mask, ether, new design , . . . . . 697

— use of, in treating plague cases . . 439

IMassage in alopecia areata . . . . 90

— apparatus, the '* Poso ” . . . , 707

— in chorea . . . . . . . . 495

GENERAL INDEX

PAGE

Massage in fibrositis . . . . . . 24.0

— gonorrhoeal arthritis . . . . . . 26S

— Graves’ disease . . . . . . 264

— and movement in tractures . . . . 246

— in rheumatoid arthritis . . . . 125

— therapeutic indications for . . . . 16

— in tinnitus . . . . . . . . 613

Mastoid disease (see Otitis Media)

— operation, after-treatment . . . . 403

in children. . . . . . . . 401

for labyrinthitis . . . . . . 326

persistent otorrha?a of children . . 397

skin grafting after . . . . 402

Mastoiditis.. .. .. .. 40-

Masturbation in etiology of orchitis in

children 394

Materia medica, dictionary’' of . . . . i

Measles 363

— erythema complicating . . . . 232

— leucocyte count in diagnosis from

rubdla . . . . . . . . 498

— otitis in . . . . . . . . 396

Meat, underdone, in Graves’ disease . . 264

— unsound, decision re warranty of . . 684

Blechanical measures in bronchitis in

children . . . . . . . . 164

Meckel's diverticulum, surgical aspects of 302
Mediastinal pressure, early diagnosis of . . 364

Mediastinal tiimonrs . . • . 364

Medical gy’mnastics for mentally-deficient

children .. .. .. .. 17

— institutions, homes, spas, etc. . . 752

— officers of schools, legal decisions re. . 682

— official and trade directory . . . . 776

— and scientific periodicals, etc. . . ?8o

— scientific societies • . . . . . 779

— and surgical appliances . . . . 689

progress, review of . . . . 77

Medico-legal and forensic medi-
cine 670

IMediterranean, form of anaemia endemic

on shores of . , . . . . 96

Meloena neonatorum 272

Melanotic tumours, primary, of rectum 482
Membranes, pericolic , . . . . . 430

Menopause, artificial, ovarian grafting for 365

— disturbed or artificial, glanduovin in ii

— sumbul of no value at . . . . 31

Menorrhagia, erystipticin in . . . . 9

— synthetic hydrastinin in . . . . 13

Meningitis, epidemic (see Cerebrospinal

Eever) . . . . . . . . 1S6

— gummatous, association with diabetes

insipidus . . . . . . . . 200

— otitic . . . . . . . . . . 404

(see Otitis Media) . . . . . - 365

operation in prophylaxis of . . 406

results of operation . . . . 405

— .after removal of adenoids . . . . 88

— in sj’philitic children . . , . . . 21S

Mening'itis, tuberculous . . . . 365

Mens tinial bleeding, e.xcessivc, erystypticin

in . . . . . . . . . . 9

Menstrual disorders . . . . 365

Menstruation, ca.sts passed in . . . . 366

— excessive, synthetic hydrastinin in.. 13

l^ensuration in diagnosis of pregnancy 455
Mental cases, luminal as sedative in . . 16'

— complaints, seminal vesiculectomy in 504

— defects and enuresis . . . . . . 228

relation to congenital syphilis . . 598

and syphilis . . * . . . . 59O

Mental diseases 366

Abderhalden’s test in .. .. 152

hypnotism in . . . . . . 564

— excitement, aleudrin in . . . . 3

— powers, pineal gland extract in stimu-

lation of . . . . . . . . 434

— symj^toms in cerebrospinal syphilis . . 586

PAGE

Mental symptoms in pellagra .. 417, 426

— treatment, institutions for . . . . 753

Mentally defecti\’e children, legal deci-
sion re . . . . . . . . 682

medical gymnastics for .. 17

Menthol, camphor, and chlomJ in fibrositis 238
Merck's fuchsine medicinal in chronic

ulcers 647

Mercurial stomati ;is, salvarsan in .. 27

Mercuric soap, “ aseptoid ” .. .. 725

Mercury (see Syphilis) . . . . . . 574

— arsenic paste in cancer . . . . 178

— in cerebrospinal sj'philis . . .. 591

— colloid, in furunculosis . . . . 254

— congenital syphilLs .. .. 58 1

— endemic anaemia of children. . .. 97

— in heart disease . . . . . . 282

— injections in microbial infections . . 18

simple solitary ulcer of bladder. . 147

— in intestinal dyspepsia of diildren . . 216

— iodide in lupus erythematosus . . 350

— lotions in otitis media . . . . 399

— ointment in eczema . . . . . . 221

— in pellagra 427

— > perchloride lotion in cataract opera-
tions 1S3

— in phlyctenular conjunctivitis . . 195

— psoriasis . . . . . . . . 464

— pyelitis of children . . . . . . 473

— and salvarsan combined treatment . . 374

— for stout bronchitics . . . . . . 166

— in syphilis of tire liver. . . . . . 344

— syphilitic arthritis . . . . . . 128

heart disease . . . . . . 277

— yellow oxide, new preparation of . . 732

Mercuiy-sulfamino-dimethyl-plienyl py-

razolon in syphilis ' . . * . 578

Mesbe, 3 new remedy for tuberculosis . . 1 8

Meseutery, swelling’s arising in 368
Mesothorium in skin diseases . . . . 514

— (see Thorium), nature and properties 60

Metabolic disorders, sih^er arsenite in . . 4

MetaboHsm, carbohydrate, factors influ-
encing . . . . . . . . 201

Metallic antimony in sleeping sickness . , 621

Metals, curative action on carcinomata of 18
Metastatic nodules wfith Bence-Jones

proteinuria . . . . . . ’ . . 464

Methylene blue in tuberculosis in child-
hood .. .. .. .. 62S

Mett’s tubes for test for protease , . 4 1 1

Michel’s sutures, new forceps for clamp-
ing . . . . . . . . . . 69S

■Jlicrobes, distribution in intestine . , 236

Microbial infections, mercury injections in iS
Micrococcus catarrhalis, differentiation

from gonococcus . . . . , . 266

— tetragenus, causing disease simulating

acute phthisis . . . . . . 505

— zyniogcnes, association with ulcera-

tive endocarditis . . . . . . 225

Micrometer eyepiece, “ step ” . . , . 708

Micro-organisms causing goitre . . . . 261

hlicroBcopes, impro’/cmcnls in . . . . 708

Microtia, congenital bilateral .. 216

Micturition, painful, in women . . . . 145

Middle-ear deafness as cause of vertigo 666

— disease (see Otitis Media) . . . . 395

— disease, excretion of urotropin in pus in 13

— inflammation, diagnosis of . . . . 217

— syphilis of .. .. .. ,. 219

Milk adulteration, legal decision re , . 677

— diet in cirrhosis of the liver . . . . 341

sprue 347

typhoid fever, insufficiency of 643, 644

— in etiology of surgical tuberculosis . . 636

— flow, cotton-seed "extract inducing . . 7

— pancreatized, in rectal feeding . , 483

— relative value of boiled and unboiled 299

CVl

GENERAL INDEX

PAGE

Milk and luberculosis, Board of Agricul-
ture Order re . . . . . . 675

— as vehicle for disseminating B. typhosus 638

— whole cit rated, in infant feeding . , 300

j\rilkshops, legal decision re . . . , 680

Milroy’s hereditary trophoedema, relation

of “ blue brain ** to . . . . 548

Miners’ nystagmus, causes and symptoms 685
Miscarriages caused by diachylon . . 685

Mitral d%varfism . . . . . . . . 279

Mongolian marmot in relation to plague 439
MonUii fimgi, relation to sprue . . . . 547

Morphia in aortic aneurysm * . . . in

— and ether in renal colic . . , . 315

— in cancer of cesophagus . . . . 388

— pre-aneesthetic use of 103

Morphine hypophosphite (hj'podormic),

tabloids of . . . . . . . . 720

Morphinism, suggestion treatment of . . 565

Mosquito-proof house for tropics . . 351

Mosquitoes and dengue .. .. 499

— in etiology of yellow fever . . . . 669

Motor cars, legal decisions re . . . . 680

— spasms, ureabromine as a sedative in 32
Mouth-breathing after removal of

adenoids . . . . . . . . 88

Movable kidney, operations for . . . . 313

Movements and massage in fractures . . 246

— passive, in gonorrhoeal arthritis . . 268

Mucous colitis in children . . . . 214

— membranes, anaesthetizing effect of

potassium permanganate on . . 22

radiotherapy in epitheliomata of 51

Mumps 368

— relation to acute interstitial parotitis 415
Miinster-a-St. radium emanations in

rheumatic affections . , . . 66

Musde fibres, intestinal digestion of . . 235

Musdes, exercises for 17

Muscular affections, rheumatic, radia-
tion in . , . . . . . . 66

with sporotrichosis . . . . 546

— rheumatism {see Fibrositis) . . . . 237

— sderosis in isdiaeniic myositis . . 370

— wasting in rheumatoid arthritis,

massage for . , . . . . 123

Mutism, hysterical, suggestion treatment

in . . . . , . . . . . 565

Mycetoma 369

Mycosis fuugroides 369

.r-rays in 513

Myeloblasts, to distinguish from lympho-
cytes .. .. .. 335

Myeloid leuka?mia, ;i:-ray treatment of . . 47

Myelomata, multiple, nnth proteinuria . . 464

Mydopathic polycythaemia . . . . 453

Myocardial degeneration and auricular

fibrillation . . , . . . . . 130

Myocarditis, syphilitic 373

Myomata, danger increased with age in 661

— of bladder, operation for . . . . 140

— treatment by radiation , , . . 65

— uterine .r-ray treatment of . . . . 45

Myopia ; is it decreasing ? . . . . 483

Myositis, isclieemic 369

— ossificans traumatica, :r-ray diagnosis 43

N ag-ana in etiology of sleeping sick-
ness,. .. .. .. 620

Nails, familial dystrophy of . . . . 274

Narcotics, pre-anaesthetic use of . . . . 102

N^vi, carbon dioxide snow in . , . . 313

— mesothorium for .. .. .. 514

— radiotherapy in , . . . . . 32

Nasal accessory sinuses . . . . 371

infection after removal of

adenoids 88

— catarrh, vaednes in 383

— deformities 3S1

PAGE

Nasal disease in catisalion of asthma . . 128

— duct obstruction, operative technique

for 327

— inhaler, new design 7o.j

— operations, pituitrin in lessening

haemorrhage after 23

— passages, treatment in rheumatism

in childhood . . . . . . 494

— pundies, etc., universal handle for . . 700

— thermometry 381

— work, noviform in 19

Nascent iodine in phthisis . . . . 635

Nasopharyngeal fibroma, operation for 382
Nasopharynx, arsenical compoimds in

syphilis of 385

National Insurance Act, garnisheeing for

fees due to doctors under. . . . 671

legal decisions under . . . . 680

liability of panel doctor under 670

and malingering . . . . 334

Nauseant effect of digital^ bodies . . 8

Nebulizer, pocket , . . . . . . . 709

Neck, cystic h-ygroma of . . . , 35^3

Neckband, tight, in relieving tinnitus . . 613

Necator americanus, differentiation from

ankylostomum . . . . . . 649

Necrosis of tissue, action of carbenzyme

on . . . . . . . . . . 6

Necrotic changes, thorium causing , . 64

Neosalvarsan (see Salvarsan) . . . . 25

— in aural syphilis . . . . . . 219

— benign tertian malaria . . . . 353

— compared with salvarsan . . . . 575

— in interstitial keratitis . . . . iyS

— powder for chronic ulcers . . . . 515

— in syphilis of nose and throat . . 385

— treatment of pregnant women . . 585

Nephrectomy, mortality from . . . . 319

— for pyelitis in childhood . . . . 474

Nephritis 373

— adrenalin in 3

— agrael in 72 s

— pregnancy with 456

— protein-free diet in . . . . . . 375

— relation of arterial hypertension to . . 373

— squill as a diuretic in . . . , 30

Nephrolithiasis . , 314

— seminal calculi simulating . . . . 503

Nephrolithotomy, bilateral, indications

. ^or 315, 316

— ■ in children .. .. .. .. 31G

Nephropexy for movable kidney . . 313

Nephroptosis .. .. . .. 313

— operations for 313

Nerve blocking, or regional amesthesia . . 108

— diseases, suitable or not for hypnotic

treatment . . 564

— division in larjmgeal tuberculosis . . 331

— relapses after salvarsan treatment 574, 592

— roots, sutgerj' of 524

intrathecal anastomosis of . . 527

j — tonics, new glycerophosphate com-
binations for 728

Nerves, intercostal, avulsion for visceral

' crises 526

Nervous affections, rheumatic, radiation in 66

— children, value of massage for , . 1,6

— complaints, seminal vesiculotomj'' in 504

— conditions, neubomyval in . . . . 19

— diseases, general review of .. .. 81

— excitement, cardiac, ureabromine in 32

— l^ions of pellagra .. .. 417, 426

— origin of psoriasis . . . . . . 465

tinnitus aurium . , . . . . 612

— sleeplessness, paracodin as a hyp-

notic in .. .. ., 21

— symptoms of chronic prostatitis and

vesiculitis . . . . , , . 462

pj’clitis in diildren . . . . 472

GENERAL INDEX

evil

PAGE

Nervous symptoms of rheumatism in

childhood . . . . , . . . 493

stimulating effect of thorium-a: on 65

NesEeld’s dislocator in cataract operation 184
Neubomyval in nervous conditions . . 19

Neumann “ noise apparatus ” in laby-
rinthitis . . . . . . . . 326

Neuralgia, aleudrin in . . . . . . 3

— after herpes zoster, ionic medication in 294

— high-frequenev currents in . . . . 55

— ionic medication in . . . . . . 59

NTeuralgria, trigreminal . . . . 377

ITeiirastlienia, traumatic. • • . 379

— sumbul of no value in . . . . . . 31

— traumatic, malingerers and . . , . 360

Neuritis, retrobulbar, guaiacol diaphoresis

in . . . . . . . . . . 234

Neuro-recurrences after salvarsan treat-
ment 574, 592

Neuroses, functional, malingerers and . . 360

* — sexual trauma in production of 466, 563
New tuberculin . . . . . . . . 71

Newly-bom, hsemorrhages in . . . . 272

— prophylaxis against ophthalmia in . . 196

— umbilical infections in . . . . 648

Nigeria, prevalence of hookworm disease

in . . . . 650

Night terrors, belladonna and potassium

bromide in . . . . . . 229

Nikolsky’s sign in pemphigus foliaceus . . 428

Ninhydrin in test for pregnancy . . . . 454

Nipples, cracked 297

Nitrogen retention, estimation of . . 488

— in urine, tests for 657

Nitrous oxide anaesthesia in major surgery 102

Nodular leukaemia 336

Nodules, metastatic, with Bence-Jones

proteinuria . . 464

— subcirtaneous, of calcium . . . . 174

Noguchi’s luetin test in syphilis . . 570

— test for albumin in cerebrospinal fluid 189

— rabies virus 476

Noises in the ear (see Tinnitus) . . - . 612

Nonne’s tests for albumin in cerebrospinal

fl.uid 189

Nose 380

— deformities of .. .. .. 381

— influence on temperature of inspired air 381

— lupus of, nascent iodine in . . . . 382

— malignant disease of 382

— plastic surgery of 496

— and throat diseases, review of . . 82

NTose and. throat, general thera-
peutics of 382

Notes . . . . . . . . • . 787

Noviform, a new substitute for iodoform 19
Novocain ansEsthesia in spinal surgerv* . . 524

— - with general anaesthetic in major

surgery . . . . . . . . 104

— injections in sacral canal in sciatica, . 501

— local anaesthesia in lung surgery . . 346

Nurses, addresses of . . . . . . 793

Nursing iiialitutioiis and homes . . . . 768

Nux vomica in fibrositis . . . . . . 23S

intestinal dyspepsia of children., a 16

Nystagmus with labyrinthitis . . . . 326

— miners’, causes and symptoms . . 685

O ATMEAL cure in diabetes . . . . 202

O’Beirne’s valve in diagnosis of

appendicitis 117

Obesity, adjuvant effect of thorium-x in 66
— in angina fectoris, treatment .. 114

— leptynol for . . . . . . . . 15

— treatment of bronchitis in . . . . i56

Obstetrics, general review of . . . . bo

Occupation incidence of pellagra . . 419

— neuroses, suggestion treatment and 565
— in spinal curvature . . . . . . 340

PAGE

Occupational brass-poisoning . . , . 686

— eczema . . . . . . . . . . 222

Ocular musdes, disorders of (see Strabis-
mus) . . . . . . . . 556

(Edema of heart failure, squill in . . 30

— knee joints in rheumatoid arthritis. . 3:24

— sub-glottic, post-bronchoscopic . . 170

(Esophageal affections, .r-ray diagnosis of 41

— cancer, gastrostomy for . . . . 554

radium and x-rays in . . . . 46

— cancerous stenosis, intubation in . . 170

— lesions, examination of . . . . 391

(Esophagometer for measuring dilated

oesophagus 390

(Esophagoscope, Lewisohn’s telescopic , . 171

(Esophagoscopy in diagnosis of cancer. . 387

— in diagnosis of cardiospasm . . . . 390

— for foreign bodies 166

CEsophag'Us 3S5

— cardiospasm with sacculation of . . 390

— cicatricial stricture of . . . . 3SS

— diphtheria of . . . . , . . . 200

— malignant disease of 385

— peptic ulcer of . . . . 390

— syphilis of . . . . . . . . 389

Offensive trades, legal decision re .. 6Sr

Official and trade directory . . . . 778

Oil injections tor ureteral calculus . . 650

— immetion in multiple subcutaneous

calcinosis 173

— in treatment of spinal curvature . . 540

Ointments in pellagra . . . . . . 41 S

Olive oil in cancer of oesophagus . . 3SS

typhoid fever 645

Omental cuff in treatment of gastric ulcer 551
Omentum, importance in promoting

peritoneal adhesions . . . . 432

Omnopon, all the allcaloids of opium . . 730

Open-air treatment of stout bronchitics 166

surgical tuberculosis . . . . 637

Operating tables, new designs . . . . 710

Operation in Graves’ disease .. 263

— nasal, effect on asthma . . . . 12S

— wounds, iodine as sole dressing to clean 14

Operations on anaemic subjects . , . . 102

— complications following . . . . 391

— on diabetes . . . . . . . . 205

— on nose, etc., pituitriu in lessening

haemorrliage after.. .. .. 23

— noviform in . . . . . . . . 19

Operative findings in gastric ulcer . . 257

— and non-operative treatment of frac-

tures . . . . . . . . 242

Ophthalmia neonatorum, incidence of . . 190

ionic medication in . . . . 50

— sympathetic, guaiacol diaphoresis in 233

Ophthalmic work, novifonn in . . . . iq

Ophthalmology, general review of . . Sa

Ophthalmoscope in diagnosis of sinus

thrombosis.. .. .. .. 407

Opium alkaloids, indications for omnopon 730

— in cancer of prostate . . . . , . 462

— congenital pyloric stenosis . . . . 4 75

— gangrene . . , . , . . . 20

— heart disease . . . . . . . . 2S2

— intestinal dyspepsia of diildren . . 216

— lientery in children .. .. .. 216

Opsonic index in phlyctenular conjuncti-
vitis.. 194

plague 440

and tuberculin dosage . . . . 73

in tuberculosis, use of . . . . 149

Optic atrophy, association with diabetes

insipidus . . . . . . . , 200

Oral sepsis, association with ulcerative

endocarditis .. .. .. 227

in etiology of gastric cancer . . 549

Orchiitis, acute primary . . . . 394

Organotherapy in skin diseases . . .. 515

GENERAL INDEX

CVlll

1PAC13

Oriental sore fstv I/jiHlimauiasis) . . 331

Oruitliorlotus nitnibfita iu ctiolo.tjy of

rclapsiiic: fever .. .. .. 541

Orpimeiit in hypertrichosis . . . . 203

(^scal tampons (suprarenal extract) for

uterine hieiuonhagc . . . . 730

Osier’s disease 453

Osteitis, A-ray diagirosis of . . . . 43

Ostco-arthritis of hip joint . . . . 294

— malingerers and . . . . . . 357

Osteomalacia, anovavthyroid serum in 3
OsteomycUts, acute, serum treatment of 29
vaccine therapy in . . . . 36

— following removal of adenoids . . 88

— from nasal sinus suppuration , , 371

Osteoporosis, blue selerot'ics associated

with.. .. .. .. .. 503

Otitic meningitis 40

results of operation . . . . 403

Otitis, exanthematic . . . . . . 396

Otitis media 395

— excretion of urotropin in pus in.. 13

chronic non-purulcnt . . . . 398

pain in diagnosis of .. .. 2t7

prognosis . . . . . . . 398

— technique of hearing tests in . . 398

• treatment . . . . . . . . 399

Otorrhcea, persistent, in children, follow-
ing infections . . . . . . 397

Otosclerosis, brilliant results wifh radium 409
Ova, effect of thorium on . . . . 63

— method of demonstrating in fseces . . 236

Ovarian lesions, relation to spinal

deformity .. .. .. ..530

Ovarian tumours . . . * . • 409

— grafting in artificial menopause . . 36s

— preparations, subcutaneous adminis-

tration of . . . . . . . . I r

Ovaries, effect of filtered A--rays on . . 45

Ovariotomy for tumours during pregnancy 409
Ovary, acute enlargement, following

mumps 369

Oxalic acid poisoning, lime salts in . . 20

Oxygen appliances, new designs . . .. 710

— in croupous pneumonia . . . . 442

— injection to avoid danger in aspirating

pleural cavity . . . • . . 354

— insufflation as an intestinal disinfectant 20

— with nitrous oxide in major surgery 102

— in pregnancy toxaemia . . . . 457

— for stout bronchitics 166

Oxy-proteixi-acid-nitrogen iu urine . . 657

OzsBUa 410

— ionic medication in 59

— vaccines in . . . . . . , . 384

Oy-oline antiseptic and deodorant . . 730

Ozone, little value as a gaseous disinfect-
ant . . , , . . . . . . 21

P ACKARD, E. N., 68 ; Perkins, J. J.,

128, 162, 164, 199, 222, 364, 441,

442, 445, 629 ; Pierce, B., 366,

379 , 466, 595 ; Porter, W. G., 88,

166, 324, 328, 37t, 380, 383, 385,

410, 616 ; Priestley, J., 670

Packs, warm, in chorea 495

Pallor and anaemia, importance of distin-
guishing between 96

Palmar arch, superficial, aneurysm of . - 112

Pancreas, accessory 412

Pancreas, functional activity of 410
Pancreas, laboratory diagnosis

of diseases of 41 1

— relation of diabetes-mellitus to , . 201

Pancreas, surgery of .. ..412

Pancreatic achylia, character of faeces in 236
— disease, intestinal origin of . . . . 204

— ferments, results of investigation not

trustworthy . . , . . , 413

I>AC.E

Pancreatic inadequacy in children .. 215

Pancreatin in pernicious antemia . . 10 r

Pancreatitis, abscess of lesser sac follow-
ing 412

Pancreatitis acute 4x3

— chronic, amylolytlc-ferment test in 658

Pancreatized milk in rectal feeding . . 483

Panhysterectomy, indications for . , 660

— vaginal clamp for . . . . . . 693

Pantopon, all the allorloids of opimn . . 73b

Papilloedema, gnaiaeol diaphoresis in . . 234

Papilloma of bladder, high-frequency

current in 14 1

Paracentesis in aural syphilis . , . . 219

— danger of 345

— in hydro thorax 279

— pericarditis, technique . . . . 43b

Paracodin, a new codeia preparation . . 730

— as a sedative and hypnotic . . . . ai

Paraffin in arteriosclerosis . , . . 122

— injections in ozoeiia 410

— for stout broncliitics 166

Paraldehyde in intravenous anaesthesia 107
Parab'sis, anaesthesia 107

— of bladder, nerve-root anastomosis for 527

— epidemic poliomyelitis . . . . 451

— general (see Syphilis, Cerebrospinal) 58G

— laryngeal 331

— post-operative intestinal, effect of

pituitary extract on . . . . 23

— of recurrent nerve, bronchoscopy in 170

from goitre 606

muscles, caused by magnesium

salts . . . . . . . . 600

Paralytic phenomena, hysterical, sugges-
tion treatment in 565

Paraplegia, spinal tumours in etiology of 510

— in thoracic aneurysm . , .. 109

Parasites causing appendicitis . . . . 116

Parasitic infections, new method of

applying sulphur in . . . . 31

— thyroiditis . . . , . . . . 261

Parasiticide, resorcin as a . . . . ,*507

— salicvlic add as a 508

— sulphur as a . . . . . , . . 509

Parasitology of black water fever . . 139

Parasyphilis, luctin reaction in . . . . 571

Parasyphilitic diseases, iinsatisfactoiy

position of therapeutics of 590, 596

Paratyphoid, colloidal silver in . . . . 30

Paratyphoid fever . . . . 414

Paresis (sec Paralysis)

Paretic muscles, exerdses for , . , . 17

Parinaud’s conjunctivitis . . . . 196

Parofex, a new paraffin preparation . . 730

Parotitis (see also Mumps) . . . . 41:4

Paroxysmal tachycardia., .. .. 285

Parturition, management of dystopic

kidney in 312

Passive hypenemia in gonorrhoeal arthritis 368

— movements in rheumatoid arthritis 125

Pasteurization of milk, advantages of . . 290

Patella, section- of, in fractured spine of

tibia . . . . . . . . 333

Pediculosis capitis 415

Pelvic affections diagnosed as appendi-
citis 115

Pellagra . . . . . . . . 4^6

■— diagnosis 417, 426

— etiology 4 x 8 , 424

— history and distribution .. 416, 424

— prognosis 41S, 426

— symptoms .. .. 416,417,425

— treatment .. 41S, 423, 427

Pellidol dressing after mastoid operation 403

— in intertrigo and eczema . . . . 2a

Pemphigus 427

— foliaccus . . . . . . . . 428

— human blood in .. .. ..513

GENERAL INDEX

CIX

PAGE

Penile hypospadias, operation for .. 651

Penis, bone formation in . . . , 428

Penis, surgery of 42S

— tuberculosis of . . .. .. .. 428

Pennyroyal, oil of, small emmenagogue

value of . . . . . . . . 9

Peptic ulcer of oesophagus . . . . 390

Peptone in rectal feeding 483

Pcrchloride of iron in ringworm. . . . 498

— mercury lotion in cataract operations 183

in microbial infections . . . . iS

Percussion in diagnosis of tuberculous

bronchial glands 163

typhoid fever . . . . . . 64b

— fractures . . . . . . . . 244

Pereis’s bacillus and ozaena . . . . 410

Pericardial effusions, drainage of . . 429

r-ray diagnosis of . . . . . . 43

Pericarditis 429

Pericolic membranes .. .. 430

Perineal prostatectomy, urimary fistulte

after.. .. .. .. .. 652

Wilms* method of . . . . . . 460

Periodicals, medic. il and scientific . . 780

Peripheral circulation, stasis of . . . . 548

Perisplenitis with splenomegaly. . .. 545

Peritoneal adhesions, methods of pio-

moting 432

Peritonitis 432

— excretion of urotropin in pus in . . 13

— sea-water in . . . . . . . . 25

Permanganate of potassium, anaesthetiz-
ing effect on mucous membranes 22

in gonorrhoea 267

poisoning amongst workers in . , 687

in snake-bite 518

Permanganates in cholera . . . . 192

Pernicious anaemia 98

causes in children . . , . . . 96

relation to bone-marrow cancer. . 98

salvarsan in . . . . . . 99

splenectomy for . . . . . . 546

thorium-A; in . . . . 66, 100

— malaria 353

Perogen salt baths . . . . . . 730

Peroxide of hydrogen in cancer of

oesophagus . . . . . . . . 38S

gerraicid^al efficacy of preparations

of 13

in inflammations of the eye . . 233

Peroxides in hypertrichosis . . 296

Persuasion method of treatment . . 562

Pertussis 433

Petroleum in spinal cuiwature . . . . 540

Petromol, a new paraffin preparation . , 730

Petruschky’s tuberculin ointment . . 73

Pharj'ngeal insufllation ana?stliesia . . 106

Phar^mx, salvarsan in ulcerations of . . 384

Phenacetin for headache during lactation 298
Phenazone in asthma of children . . 130

Phenol (see Carbolic Acid) . . . . 604

Phenolphthalein in infantile eczema . . 221

Phcnosulphonephthalein test of renal

activity 4S5

Phimosis as cause of enuresis . . , . 228

Phlebotomus fever (see Sand-fly Fever)
Pfclegmon, ligneus, of abdominal wall . . 85

Phloroglucin test in urinary infections 655
Phlyctenular coniunctivitis . . . . 194

Phobrol (clilormetacresol) as an antiseptic 6
Phosphoric acid in pyelitis of children . . 474

Phrenocardia, a cardiac neurosis . . 278

Phthalein test of renal activity . . . . 485

Phthisis (see Tuberculosis)

— simulated by actinomycosis . . . . 86

— value of AT-ray findings in . . . . 42

Phylacogen injections in rheumatoid

arthritis 127

— treatment of rheumatism . . . . 37

PAGE

Phylacogens, varieties and uses of . . 730

Physostigmine, effect on paroxysmal

tachycardia . . . . . . . . 285

Picric acid and camphor in ringworm . . 497

for wounds . . . . . . . . 22

Picrotoxin in Graves* disease . . . . 264

Pigmented areas, sulphur for .. .. 510

Pigments in urine, tests for , . . . 658

Piles (see HEemorrhoids)

Pilocarpine in labyrinthine vertigo . . 666

— tinnitus.. .. .. .T .. 613

Pineal extracts, physiological action of 435
Pineal grland, functions of . . . . 434

Pini sed., a new antipruritic ointment . . 731

Piperonal, preparation of, hydrastiniii

from . . . . . . . . 13

Pituglandol, rupture of uterus after . . 22

Pittoary body, diseases of . . 435

relation to diabetes insipidus . . 200

mellitus . . . . . . 201

thyroid 515

— extract in Graves’ disease . . . . 264

ph3^siological action of . . . . 435

in pneumonia . . . . . . 443

therapeutic indications and effects 22

— and pineal gland defects, comparison of 43.^
Pituitrin and adrenalin, good results of

combining . . . , . . . . 24

— in diolera 193

Pityriasis simplex of scalp, sulphur in . . 510

Plague 437

— mode of infection . . . . . . 438

— report of English Commission on . . 439

— treatment 440

Plant growths, effect of thorium on . . 63

Plant-Vincent angina, salvarsan in 27, 385
Plaster, adhesive, as direct dressing for

wounds .. .. .. .. 514

— spica in fracture of neck of femur . . 250

Pleural effusion 441

— significance of, in diagnosis of tubercu-

losis 633

— tuberculous, injections of infusion in 441

Plumbism and the sale of diachylon . . 681

Pneumococcal arthritis, vaccine therapy

in 36

-7- infection in otitis media . . . . 395

I Pneumococci, specific action of camx^hor
; against . . . . . . . . 6

! Pneumonia 442

' — as an accident. . . . . . . . 671

; — colloidal silver in , . . . . . 29

j Pneumonia, epidemic . . . . 443

I — gangrene complicating .. .. 254

I — and heart block . . . . . . 288

' — post-operative . . . . . . 392

j — vaccine therapy not serviceable in . . 36

I Pneumonic plague . . . . . . 437

Pneumosau, a new remed\’ for tubercxi-

iosis. . .. .* .. .. 731

Pneumotliorax, artificial . . 445

apparatus for .. .. .. 71 1

selection of cases . . . . . . 449

mechanical control of . , . . 346

technique of . . . . . . 445

Pneumotomy for sliawl pin in lung . . 348

— transpleural, for foreign body in lung 347
Podophjdlin in functional derangement

of the liver .. .. .. 343

Poisoning of food, bacterial . . . . 673

— by food, uzara in diarrhcca of . . 33

— manganese, symptoms and treatment 687

— salvarsan . . . . . . . . 594

Poisons, non-corrosive, action of adrena-
lin on . . . . . . . . 2

Polioencephalitis, massage in the spastic

contractions of .. .. .. 16

Poliomyelitis, acute parotitis with . . 415

Poliomyelitis, epidemic . , • . 450

GENERAL INDEX

PAGE PAGE

Pollen extract in hay lever . . 34, 384 Pregnancy, vomiting of 450

Polycythsemia 453 Presbyopia.. .. .. .. .. 484

Polylactol, a new galactagoguc . . . . 731 Prcs.siire, mediastinal, early diagnosis of 364

Polyneuritis, rice diet and . . . . 134 Primary melanotic tumours of rectum 482

Polypi of the ear 216 Pringle's operation for umbilical hernia 291

— aural and post-nasal, a cause of cough rog Prisms, prescription of 558

Polyuria, effect of pituitary gland on , . 435 Probe, tonsil, new design, . . . . . 721

— induced by pituitary extract . . . . aoo Progress of pharmacy, dietet-

Porta’s method of suturing blood-vessels 120 ics, etc 734

Portal infection, urotropin in . . . . 12 Prolapse of uterus, operation for . . 663

Porto Rico, prevalence of hookworm Propsesin, a new local anaesthetic . . 731

disease in 649 Proprietary foods in infant feeding . . 301

Port-wine stain, radiotherapy in , . 52 Prostate, cancer of . . . . . . 461

Position, change of, in bronchitis of — disappearance of glycosuria after

children . . . . . . . . 164 operations on . . . . . , 205

in croupous pneumonia .. 442 Prostate, diseases of .. .. 45S

Post-mortem examination, legal deci- — tubercle badlli in urine from . . 622

sions re . , . . . . . . 672 Prostatectomy, choice of route in . . 459

Post-nasal polypus a cause of cough . . 199 — perineal, urinary fistulas after . . 652

Post-operative complications . . . . 391 Prostatic hypertrophy, conditions simu-

— intestinal stasis complicating append!- lating 458

citis.. .. .. .. .. 116 ionic medication in .. .. 59

— prophylaxis in breast cancer, A'-rays in 46 — bars, Young’s pundi operation for . . 461

— tympanites, urotropin in . . . . 12 Prostatitis, chronic . . . . . . 462

Post-partum retroversion, cause and Protargol in Eustachian catarrh , . . 395

* treatment . . . . . . , . 324 — chronic gleet 270

Posture, characteristic, in thoracic aneu- Proteid diet in tuberculosis of childhood 628

rysm - . . . . . . . 109 — exdiange, effect of radium and

Potassium bicarbonate in pyelitis of thorium on 64

children . . . . . . . . 474 Protein restriction in gastrogenic diar-

— bromide in enuresis 229 rheea 206

— citrate in enuresis . . . . . . 228 Protein-free diet in nephritis . . . , 375

pyelitis of children . . 472, 474 Proteins, useless in rectal feeding . . 483

cholera 194 Proteimiria 462

— and gold cyanide in syphilis , . . . 581 — nodules and myelomata with . . 464

tuberculosis of skin .. 515 Protease, test for, in pancreatic secretion 411

— iodide in angina pectoris . . . . 114 Proteolytic fermentation, reaction of

aortic aneurysm .. .. .. 111 faeces in .. .. .. .. 235

— ' — arteriosclerotic vertigo . .. 666 Pruritus ani .. .. .. .. 115

asthma of children . . , . 130 resorcin in . . 507

congenital syphilis , . . . 582 — brass-workers’ 686

excretion by kidneys of . . . . 487 — hysterica^ suggestion treatment in 565

in fibrositis . . . . . . 238 — from leukaemic eruptions, ^r-rays in 340

ionization with 56 — in pregnancy, serum treatment . . 437

in mycetoma 369 — A;-rays in 513

liniment in rheumatoid arthritis 135 Prurigo of Hebra, human blood injections

in psoriasis .. .. .. 464 in . . .. .. ..512

— ■ — sporotrichosis . . . . . . 547 Pseudo-calculus of the kidney . . . . 44

syphilis of the liver . . , . 344 Pseudo-fracture of spinal transverse

syphilitic arthritis .. .. 128 processes 527

heart disease . . , . . . 277 Pseudo-glanders {see Glanders) . . . . 258

— permanganate, ansesthetizing effect Pseudo-leukaemic splenic ansemia, ,v-ray

on mucous membranes . . . . 22 treatment of . . . . . . 48

baths in psoriasis 465 Psoriasis 464

in gonorrhoea 267 — followed by mycosis fungoides . . 369

poisoning amongst workers in . . 687 — ionic medication in 59

snake-bite 518 — .t-rays in .. .. .. 50, 513

— sulphuratum, method of applying to Psychasthenia, suggestion treatment in 565

skin 30 Psycho-analysis {see also Suggestion,

Potency, effect of radio-active substances 56^) 366, 466

on . . . . . . . . . . 65 — methods . . 563

Pott’s disease, diagnosis of osteomyelitis Psychoses of puberty, auovarthyroid

from 541 ’ serum in . . ' 3

diagnosis of vertebral tumour Psycho-therapeutics {see Suggestion) . . 538

from . . . . . . . . 520 Puberty, auovarthyroid servmi in psy-

— fracture.. .. .. .. 245 choses of .. ' 3

Pregnancy, cystitis of . . . . . . 145 Pubiotomy, limitations of . . • . 3<i!5

— dermatitis in ^ 457 Public health 670

Pre^nancy,^ diagmosis of . , 453 Pudendal granuloma 271

— edampsia in ... . . . . . 456 Puerperal sepsis, vaccine therapy in . . 34

Pregnancy, ectopic . . . . . . 455 Puerperium, movement and exercises

— dialysis test of Abderhalden in ..150 in 324

— heart disease in relation to . . . . 281 — ovarian tumours complicating . . 409

— in heart disease, treatment . 285 Pulmonarj^ actinomycosis .. .. 86

— human blood in skin diseases in ^ . . 512 — complications of operation . , . . 392

— management of dystopic kidney in. . 312 — conditions, oxygen injections in acute

— ovarian tumours coniplicating .. 409 asphyxia due to 21

Pregnancy, toxasxmas of . . 455 — haemorrhage, emetine in . . . . 635

— treatment of sj’philis in . . . . 582 ^ — lesions from umbilical infections . . 648

GENERAL INDEX

CXI

PAGE

Pulmonary tuberculosis {see Tuberculosis)
Pulse, alternating.. 280

— irregular . . . . . . . . 279

in thoracic aneurysm . . . . log

Pulse-rate, effect of aconite on . . , . 1

Pulse variations in heart-block . . . . 288

Pulv. glycyrrhizae co. in arteriosclerosis 122
Pulverettes for administration ol powders 731
Pumice stone in hypertrichosis . . . . 296

Pundi operation for prostatic bars and

contracture 461

Puncture fluids 467

— in gonorrhoeal arthritis . . . . 268

Pupil reflex in cerebrospinal syphilis . . 587

Purgation, effect in heart disease . . 284

— in hydrothorax complicating heart ,

disease 279

Purin metabolism, effect of radium sub-
stances on . . . . . . . . 64

Purin-free diet in gout . . . . . . 270

Ptirpura 468

Purpura f ulminans following scarlet fever 501

— ^;-ray treatment 50

Pus, excretion of urotropin in . . . . 13

Pustules, acne bacillus as cause of . . 86

Putrefaction, intestinal, as cause of

diabetes and pancreatic disease 204

reaction of faeces in . . . . 235

Putrefactive dyspepsia and catarrh,

oxygen insufflation for . . . . 20

Pyaemia, colloidal silver in . . . . 29

Pyelitis in diildren . . . . 469

diagnosis 471

treatment 472

Pyelography in diagnosis of horseshoe

kidney 313

hydronephrosis 319

ureteral obstruction . . . . 650

Pyelotomy for stone, indications and

technique 315

Pyloric carcinoma 549

— obstruction by a gall-stone . . . . 137

Pyloric stenosis, congenital . . 474
surgical and medical treat-
ment 475

x-my diagnosis of . . . . 40

— ulcer, urotropin in . . . . . . 13

Pyne.-U-Ca health box . . . . . . 712

Pyorrhcea alveolaris in causation of

uveitis . . . . . . . . 306

Pyramidon in gonorrhoeal arthritis . , 2 68

Pyrogahol ointment in psoriasis . . . . 465

UARRYMEN, incidence of phtliisis
amongst . . . . . , . , 686

Quinine in arteriosclerotic vertigo . . 66

— endemic ansemia of children . . 697

— gonorrhoeal arthritis . . . . . . 268

— infection, with aspiration, in liver

abscess . . . . . . . . 94

in pemphigus . . . . . . 42 S

— ill lupus erythematosus . . . . 350

— moist dermatoses .. .. .. 51 1

— and urea, with general aiioesthesia,

in major surgery , . . . . . 104

pneumonia . . , , . . . . 443

Qinnoidine in malaria . . . . . . 353

Qiunton’s marine plasma in infantile

diarrheea . . . . , . . . 207

■pOGERS, L-, 90, 133. 138, 171, 191,

Iv 199, 213, 222, 258, 271, 331, 333,

350, 363, 369, 416, 437, 499 . 506,

518, 541, 547, 6ig, 649, 666, 668,

669 : Richards, G. L., 155, 216,

318, 325,, 395, 613, 666
Rabies, culture of virus of , . . . 476

— saivarsan in . . , . . . . , 27

Rabbit’s serum in chronic purpura . . 469

PAGE

Radiations, effect on normal and

pathological tissues . . , . 47

Radio-activity and electrothera-
peutics . . 38

— in etiology of cancer . . , . . . 1 78

Radiography (see A'-rays)

Radiology, review of . . . . . . 38

Radiotherapy in gonorrhoeal arthritis .. 268

— useless in endemic anaemia of children 97

Radiothorium (see Thorium) . . . , 60

Radium and allied snibstances 51
Radium, brilliant results in early oto-
sclerosis 409

— in cancer . . . . . . . . 179

— disappointing in lupus erythematosus 330

— effect on seed growth. . . . . . 38

— in epithelioma of the skin . . . . 507

— eye diseases . . . . . . . . 233

— great value of, in inoperable cancer

of uterus . . . . . . . . 660

— Institute, Report of 51

— in skin diseases 514

— and AT-raj’S compared in treatment of

cancer . . . . . . . . 46

Radius, dislocation of head, with fracture

of ulna 253,

Rag flock in bedding, legal decision re 68 r
Railway spine, malingerers and.. .. 359

organic basis for . . .. .. 519

Rainfall, relation to dysentery in India 91
Rashes complicating infectious diseases 233

Rat-bite fever 476

Rats as plague carriers . . . . . . 439

Ra3maud’s disease, association with

lupus erythematosus . . . . 350

“ blue brain ” a mild form of . . 548

Rectal cancer, diarts showing extension

of 478

radium and 4*-rays in . . 46, 5 r

Rectal diseases 478

Rectal feedingr 483

— palpation in chronic appendicitis . . Z17

— ulcers and fissures, ionic medication in 59
Rectum, primary melanotic tumours of 4S2
Red corpuscles, effect of radio-active

substances on 64

fragility of . . . . . . . . 147

Reformatories under Inebriates Act . . 766

Refraction, errors of 48 3

Regional aneesthesia in shock prevention loS
Relapsing fever (see Spiroclieetosis) .. 541

Reuaglandin (suprarenal extract) in

tampons for haemorrhage . . 730

Renal calculus . . . . . . . . 314

simulated by seminal . . . . 503

— colic . . . . . . . . • • 315

— disease a cause of intermittent limp 123

general review of . . . . . . 82

hypertensive . . . . . . 374

.r-xay diagnosis of 44

— efficiency, amyloly tic-ferment test for 658
Renal efficiency, estimation of 485

— infection, post-operative . . . . 321

— inflammations, agmel for . . , . 725

— lesions, relation to spinal deformity 530

— tuberculosis . . . . . . . . 317

Reniform in ozeeua . . - . . . 410

Reproductive glands, effect of radio-
active substances on . . . . 65

Respiratory tract, formaldehyde inhalants

in affections of . . . . . , 72S

Rest in auricular flutter 133

— eczema . . . . . . . . . . 221

— erj'thema nodosum .. .. .. 233

— fibrosifis . . . . . . . . 23S

— Graves’ disease . . . . . . 264

— heart disease . . . . . . . . 283

— hydrothorax complicating heart disease 379

— hyperpiesis . . . . . . . . i 54

cxii

GENERAL INDEX

PAGE PAGE

Rest ill post-operative thrombophlebitis 394 Roboleiiie, a sulxstiliite for cod-liver oil

— rheumatism in childhood . . . . 405 Rodent ulcer, carbon dioxide snow in . . 513

— rheumatoid arthritis 124 — of eyelids, radium in .. 233

— surgical tuberculosis . . . . . . 637 ionic medication in , . . . 59

Resonance impaired in diagnosis of mesotlioriimi in . . . . . . 514

typhoid fever .. .. .. 640 radiotherapy in . . .. 51

Resorcin in chronic conjunctivitis . . 233 Roger's hsipcrtonic saline treatment of

— ointment in kcratodermia bleunor- cholera . . . . . . . . 192

rhagica 310 Rontgen rays (se^ A'-rays)

— properties of 507 Rosacea, carbon dioxide snow in . . 513

— toxic effects from 508 — ichthyol in Sir

Respiration of air under low pressure — resorcin in 507

in intermittent lump . , . . 322 Rose spots in diagnosis of typhoid fever 641

Respiratory metabolism, stimulating Rosenoach’s tuberculin . . . . . . 71

effect of thorium on . . . . 64 Rosenbloom's tests for nitrogen in urine 637

— movement, abdominal, in diagnosis Ross- Jones test for albumin in cerebro-

of pericarditis . . . . . . 429 spinal fluid . . . . . . 189

— muscles, effect of magnesium salts Round-Ugaments, method of shortening 662

injections on .. .. .. 600 ■— worm a cause of appendicitis .. 1x7

— symptoms in thoracic aneurysm .. 109 wermolin for 37

Resection of stomach for cancer . . 553 RTilDella leucocyte count in diagnosis

Resin ointment in eczema .. .. 221 from measles 498

Rethi's method of radiography of larynx 328 Rue, oil of, small emmenagogue value of 9

Retractors, new forms of .. .. 713 Rupture of bladder 144

Retrobulbar neuritis, guaiacol diaphoresis

• in 234 QTEWART, P., 172, 229, 365, 369,

Retroflexion and retroversion of uterus, O 377, 450, 501, 358, 586, 599 *

operation for . . . . . , 663 Smith, J. S, K., 528

Retrograde incarceration of intestines .. 290 Sacral anaesthesia . . .. .. .. loS

Retroversion, post-partum, cause and Salicin in lupus erythematosus . . . . 350

treatment . . . . . . . . 324 Salicyl ionization in acute fibrositis . . 240

Re tma, diseases of . . .. .• 488 Salicylate of sodium in advanced phthisis 634

— nou-traumatic detachment of, results gonorrhoeal arthritis .. .. 2 68

of treatment 489 properties and methods of use . . 24

Retinitis proliferans, thyroid extract in 234 — test in cancer .. .. .. .. rSs

Rhubarbin intestinal dyspepsia in children 216 Salicylates in cardiac rheumatism .. 282

Rheumatic affections, radio-active treat- — dosage in acute rheumatism . . . . 491

ment of . . . . . . , . 66 — in fibrositis . . . . . . . . 238

relation to ulcerative endocarditis 225 — pericarditis . . ,429

— carditis and auricular fibrillation . . 130 — rheumatism in childhood . . . . 495

— children, special homes needed for . . 282 — rheumatoid arthritis 123

— diseases, seminal vesiculotomy for . . 504 — useless in erythema nodosum . . 232

Bhetiiaatic fever 490 Salics’lic acid in lupus erythematosus . . 350

— infection, bacteriology of . . . . 225 — — skin diseases 508

Rheumatism, cardiac, treatment and as a urinary antiseptic . . . . 33

after-care .. .. .. .. 2S3 — and benzoic acid ointment in ringworm 497

Rheumatism in childhood .• 491 — ointment in psoriasis 464

frequency and importance of .. 491 Salicylo-salicy lie acid (diplosal) . . .. 9

prognosis and treatment . . .. 494 Saline aperients in fibrositis .. .. 238

— colloidal silver in , . . . . . 29 — diuretics in heart disease . . . . 285

— gonorrhoeal, vaccine therapy in . , 35 — hypertonic, in cholera . . . . 193’

— ionic medication in . . . . . . 59 — iiifusion after operation for vesical

— muscular (see Fibrositis) . . . . 237 rupture . . 145

— not a cause of uveitis . . . . 306 — injections in infantile diarrhoea 207, 208

phylacogen, treatment of . . . • 37 in sciatica 501

— ^ in prognosis of heart disease .. 281 — solution in hcemorrhages of the ne^vly-

— relation between erythema nodosum bom.. .. .. .. .. 373

and .. .. .. .. .. 232 Salivary glands, precocious Jt-ray rc-

Rheumatoid arthritis {see Arthritis, actions after application to . 40

rheumatoid) .. .. .. 123 SaUvo3'ds, pads for absorbing saliva 714

ionic medication in . . . . 59 Salol in enuresis . . . . . . . . 229

Rhinitis, atrophic {see Ozoena) . . . . 41c — goitre 606

— vaccines in .. .. .. .. 3S3 — intestinal dyspepsia of children .. 216

Rhinophyma ^ . . . 495 — pyelitis of children 472

Rhinophyma, radiotherapy in .. .. 53 Salpingitis conserv'alive treatment of 49S

Rhinoplasty . . . . . . . . 496 . — catarrhal {see otitis Media) . . . . 395

Rhinoscleroma in Egypt . . . . . . 382 Salt, excretion by kidneys of . . . . '^7

Rib resection, anaesthesia in . . . . 346 Salvarsan 25

Rice in causation of beri-beri . . . . .133 — {see Syphilis) . , . . . . 573 et seq.

— diet in eczema . . .. .. .. 220 — in amoebic dvsentery , . .. " 93

Rickets, anovarthyroid serum in . . 3 — apparatus, new designs . . . . 714

— massage in .. .. .. .. 16 — aural sj’pliilis .. 219

Rimini’s test (modified) in urinary infec- — benign tertian malaria . . . . 353

tions .. .. .. .. 655 — biochemical action of . . .. 573

Ring'W'orm . . . . . . . . 496 — in cerebrospinal syphilis . . 589, 591

•— diagnosis _ _ . . ^ . . . . . . 496 — chorea and hydrophobia . . . ’ 27

— ionic medication in . . .. 59 — combined with mercurj^ treatment.. 575

treatment .. .. . . .. 497 — in congenital syphilis . . .. 582, 599

Rinne’s test in prognosis of otitis media 39S — contraindicated in ancurj’sm 112

GENERAL INDEX

cxiii

PAGE

fialvarsan, deaths under . . . . . . 574

— disappointing in endemic anzemia of

children . . , . . . . . 97

— in general paralysis . . . . . . 596

— interstitial keratitis . . . . . . 19S

— leprosy . . . . . . . . . . 333

— pellagra.. .. .. .. 41S, 423

— pemphigus foliaceus . . . . . . 42 S

— pernicious anaemia . . . . . . 99

— plague . . - . . . . . . . 44b

— primar\» sores of mouth and throat . . 3S4

— poisoning 594

— powder for chronic ulcers . . . . 515

— rapid cure of yaws with , , . . 66S

— rectal administration of . . . . 579

— as specific in Oriental sore . . . . 332

— in syphilitic arthritis.. .. .. 128

heart disease . . . . . . 277

— syphilis duiing pregnancy . . . . 5S2

— treatment, dangers and complications .579

— in ulcerative endocarditis . . . . 227

Sanatoria for tuberculosis . . . . 761

Sanatorium treatment in larjmgcal tuber-
culosis . . . . . . . . 330

— treatment of phthisis, results . , C34

surgical tuberculosis . . . . 657

tuberculosis u. dispensaries . . 74

Sandalwood oil in psoriasis . . . . 464

as a urinary antiseptic . . . . 33

in urinary infections . . . . 65%

Sand-fly fever 499

Sanitas-okol as larvicide in malarial

districts 352

Sanitation, influence on plague preven-
tion 439

Sanokatzin tuberculin . . . . . . 72

Saphenous-femoral anastomosis for varix 663

Sapokrol, a new germicide and disin-
fectant . . . . . . . . 731

Saponin bodies, removal from digitalis

preparations 8

Sarcoma of bone, .r-ray diagnosis of . . 43

— brain {see Brain, Surgery of) . . . . 155

— cells, inhibitory effect of gamma radi- i

ations on . . . . . . . . 47

— Graves’ disease secondary to . . 262

— interscapnlo-thoracic amputation for 95

— of nose, electrical methods in . . 382

— radiotherapy in . . . . . . 51

— of spinal cord 519

— vagina . . . . . . . . . . 664

Sauerbruch chamber in control of open

pneumothorax . . . . . . 346

Scales, spring balance for . . . . 716

Scarlet fever 409

otitis in . . . . . . . . 396

— red in corneal lesions . . . . . . 2S

dressing after mastoid operation 403

ointments, new brands of . . 731

in ozeena . . , . . . . . 410

— — poisoning from . . , . . . cS

Scliizotr>’panuni cnizi in etiology of

thj’Toiditis . . . . . . ..261

School, choice of, in lateral curvature of

spine . . . . . . . . 540

— medical officers, legal decisions re . . 682

ScJK-oolboys, cardiac efficiency in . . 278

Schwabach test in prognosis of otitis

media . . . . . . . . 399

Sciatica 501

— ionic medication for . . . . . . 59

— and malingerers , . . . . . 357

— r-ray treatment 48

Sclero-corneal trephining for glaucoma. . 259

Sderodactyly with multiple subcutaneous

calcinosis . . . . . . . , 175

Sclerosis, multiple, from spinal tumours 519

— of muscles in ischaemic myositis , . 370

Sclerotxcs, blue . . ' . . . . 502

Scoliosis (see Spine, Lateral Curvature) 52S
Scopolamine, pre-anmsthetic use of . . 103

Scurvw, salvarsan in . . . . . . 27

Seaside treatment of sui^ical tuberculosis 637
Sea- water, good results in peritonitis . . 29

— injections in infantile diarrhoea . . 207

Sebaceous cysts, electrolysis in destruc-
tion of . , . . . . • ■ 513

Sebacious byper secretion . . 503

Seborrhoea of face, resorcin in . . . . 508

— new method of applying sulphur in 31

Seborrhoeic keratosis of the lips . . . . 341

Secacosiiin, a s+erile ergot extract . . 732

Sedative, adanion and adtilin , 724

— aleudrin as-a . . . . . . . . 2

— luminal as a . . . . . . . . 16

— paracodin as a. . . . . , . . 21

— urcabromine as a . . ’ . . . . 32

Sedatives for insomnia during lactation 29S
Sediments in urine, stains for . . . . 65S

Seed growth, effect of radium on . . 3S
Seminal calculi simulating nephrolithiasis 503
Seminal vesicles, diseases of . . 503

— vesiculitis, chronic . . . . . , 462

vasotomj* for . , . . , , 50^

good results of . . . . . , 504

Scimax, a new senna prepara f ion . . 732

Sensation, loss of, malingerers and 3 58, 361
Sensitized vaccines . . . . . . 37

Septic absorption in causation of uveitis 306
Septicasmia 505

— after removal of adenoids . . . . SS

— vaccine therapy in 34

Serum analysis in diagnosis of pregnancj' 433

— antistaphylococcic, good results from 29

— blood, in hcemorrhages of the newly-

born 272, 273

— diagnosis of tuberculosis . . , . 623

— gelatinized, in hsemorrhagic syndrome

of infections diseases . . , . 640

— hsematinic, in anasmia in children . . 97

— horse (coagulose) as hiemostatic . . 726

— reaction in cancer . . . . . . 175

Senmx therapy in cerebrospinal fever . . 187

— cerebrospinal syphilis.. .. 591, 596

— chronic purpura . . . . . . 469

— congenital p3’loric stenosis . . . . 476

— of dermatitis in pregnancy . . . , 457

— diphtheria, dosage . . . . . . 209

— disappointing in Graves’ disease . . 264

— ill gonorrhoea . . . , . . 26S, 269

— plague , . . . . . . . . . 440

— pyelitis of children . . . . . . 474

— skin diseases . . . . , . . . 312

— tetanus . . . . . . . . 600, 603

— of tuberculosis , . . . . . . . r>S

— ulcerative endocarditis . . , . 227

Serofibrinous effusion injections in tub.er-

culous pleurisy . . . . . . 441

Serology of blood examination . . . . 150

Seven-day fever 506

Sex incidence in pellagra . . . . . . 417

peripheral stasis . . . . . , 54S

pyelitis of cliildren , . . . 470

rheumatism in childliood. , . , 491

Sewage disposal, legal decisions rc , . 682

Sewers and drains, legal decisions re . . 67S

Sexual abnonnalities, psycho-tlierapy in 566

— changes, effect of pineal and pituitary

glands on 435

— glands, relation of thymus gland to 515

— infantilism, dyspituitarism and . . 437

— trauma in production of neuroses 466, 563
Sliipway’s apparatus for intratracheal

ansesthesia . . . . . . . . 104

Shock, nitrons oxide ansesthesia reducing 104

— prevention, anoci-association in 77, 104

syringe for . . . . . . 702

regional ansesthesia in » . . . ro8

GENERAL INDEX

PAGE

sh-''-;:3 Act, dcci'^i. .a^ aader . . . . 6S3

Sliori-circaitiag the large intestine, late

lesulls of . . . . . . . . 303

Shoticd snbculictilar suture . . . . ^.67

Siaouider, test of malingerers for weakness

of , , . . . . . . . • 356

Sidarhoiubifolia cubilguitziana extract in

tuberculosis .. .. .. iS

Sigmoid, diverticulitis of the . . . . 303

— sinus, diagnosis of thrombosis of . . 4 07

Silicic acid in cancer . . . . . . 178

Silver arsenite, therapeutic indications. . 3

— colloidal, therapeutic indications . . eg
in hsemorrhagic syndrome of

infectious diseases . . . . 640

— iodide emulsion in renal skiagraphy . . 44

— nitrate in eczema . . . . . . 220

in Eustachian catarrh . . . . 39 s

in gonorrhoea . . . . . . 266

Simulium reptans in etiology of pellagra 420
Sinus diseases, a;-ray diagnosis of . . 43

— thrombosis 4 o 7

Sinuses, sugar as application to . . . . 30

Sinusitis 371

— acute, vaccines in . . , . . . 383

~ after removal of adenoids . . . . 88

Siphon treatment of empyema . . , . 222

Skiagraphy (see ^r^rays)

Skin affections, ouprakrol a copper prepa-
ration of . . .. .. 726

general review of . . , . . . 79

malingering in . . . . , . 361

— disinfection, alcoholic paste of kaolin

alcoholic solution of iodine for . . 14

Skin, epithelioma of . . . . 507

— eruptions in p3'’elitis of children . . 472

Skin, g-eneral therapeutics of . . 507

— lesions of pellagra . . . . 417, 426

— leukjeniic eruptions of the . . . . 340

— rashes caused by atophan . . . . 4

— reaction in carcinoma . . .. .. 175

— sterilization, chlormetacresol in , . 6

— syphilitic affections of, salvarsan in 591

Skin-grafting* 517

after excision of breast . . . . 162

mastoid operation 402

for urethral defects . . . . 655

Skin tuberculosis of .. 51 1

Sleep, hypnotic 561

Sleeping sickness {see Trypanosomiasis) 619
Sleeplessness {see Insomnia)

Sluder’s guillotine (modified) in tonsil-
lectomy . , , . . , , . 6x7

Small-pox 518

Smoke nuisance, legal decision re . , 684

Snake-bite .. 518

Snake- venom treatment of epilepsy . . 231

Soamin in pellagra 418

Soap, “ aseptoid,” mercuric . . , . 725

Soaps in eczema . . . . . . . . 231

Societies, medical and scientific. . . . 779

Sodium arsanilate in pellagra . . . . 423

— bicarbonate in angina pectoris . . 1 14

pyelitis of children . . . . 474

with salicylates in acute rheumat-
ism . . , * . . . . 491

— citrate in infants’ milk . . . . 300

non-traumatic detachment of

retina 490

— hydrate in ringworm 49S

— nudeinate in cerebrospinal syphilis

589, 592

— peroxide in h^ertrichosis . . . . 296

— phosphate, add, action on urine of . . 32

in urinary infections . . , . 654

in enuresis . . . . . . . . 229

pyelitis of children . . . . 472

— salicylate in advanced phthisis . . 634

PAQi-

Sodium sarx3 late in chorea . . . . 495

fibrositis . . . , . . . . 238

properties and methods of use . . 24

— salts, infusion in pregnancy toxEemia 458

— sulphate in functional derangement

of the liver . . . . . . 343

intestinal d3’spepsia of children 21O

Soil for residence in librositis . . . . 241

Solidification of lung, methods of producing 348
Soluble ferments of body, effects ot "

thorium ou . . . . , . 63

Sophol in Eustachian catarrh . . . . 395

Soimds, heated, in gononhoea . . . . 2 68

Spa treatment in arteriosclerosis . . 122

fibrositis .. .. .. ..241

Spas, principal British . . . , , . 770

Spastic contractions, resection of nerve

roots for . . . . . . , . 325

vSpectacles, prescription of . . . . 55S

Sphenoidal osteom3'elitis after removal

of adenoids ' . . . , . . S 3

— sinus suppuration, operation for . , 371

— . — r-ra3' diagnosis of diseases of . . '43

Sphygmoinanonictry, harm done by

excessive .. .. .. 122

Spinal analgesia, favourable reports on 107

in prosiatectoni}' . . . . . . 460

sciatica . . . - . . . . 501

— cord diseases, .r-ray treatment of . . 49

Spinal cord, surgery of .. .. 519

— deformit3% relation of visceral lesions to 529

— disease, malingerers and , . . . 35 S

— tumours . . . . . . . . 519

diagnosis and treatment.. .. 523

Spine, auscultation over, in diagnosis of

tuberculosis of bronchial glands 163
Spine, injuries to 527

— lateral curvature, general rules of

treatment in . . . . . . 540

Spine, lateral curvature : treat-
ment of exercises . . . . 528

Spine, osteomyelitis of . • • . 541

— of tibia, fracture of . . . . . , 321

— typhoid 630

Spirit lamp, improved . .. .. 713

Spiritus saponis kaliuus in eczema , . 22 x

Spirochicta pallida in general paral3‘tics

569, 595

life history of 568

Spirochades, biochemical action of sal-
varsan ou . . .. .. .. 573

Spirocbsetosis 541

— local, salvarsan in 37

Spleen, cysts of 54.3

— gunshot wounds of . . . . , . 85

— lesions, relation to spinal deformity 530

— a:-ra\’S applications to . . , . 47

Splenic anaemia , . . . . . . . 544

infantile, on Mediterranean shores 90

Splenectomy for cystic disease . . . . 544

— splenic anaemia , . . . . . 97

— splenomegaly 544

Splenocytic leukaemia . . . . , . 335

Splenomedullary and l3nnphatic leukae-
mias, interrelationship . . . . 335

SplenomegaJic polycythaemia . . . . 452

Splenomegraly yn.4

— infantile, z-ray treatment of. . . . 48

Splint material, non-inflammable cellu-
loid 715

Splints for fractured femur . . . . 244

Sponges, improved surgical . . . . 71b

Sporotricbosis 54 t>

Sprays, bacterial, in diphtheria. . . . 210

— improvements in . . . . . . 716

Spring catarrh, radium in . . . . 233

I Sprue 547

Sputum : laboratory tests . . 547

I — albumin test in tuberculosis, . . . 547

GENERAL INDEX

CXV

PAGE

Sputum, stain for cells in . . . . 54.8

— tubercle bacilli in stainiu? metliods 622

Squill in auricular fibrillation . . . . 2S3

— diuretic properties of . . . . . . 30

Squint {see Strabismus) . . . . . . 556

Stab wounds of heart . . . . . . 2S6

Stammering, suggestion treatment in . . 565

Staphylococcal origin of uveitis . . . , 307

— lesions, value of vaccine therapy in 34
Staphylococcus aureus in etiologj’ of

’ osteomyelitis of spine . . . . 541

— in empyema . . . . . . . . 223

— etiology of phlyctenular conjunctivitis 194

— specific action of sandalwood oil on 33

— spra3's in diphtheria carriers. . . . 210

StaphNdoid coccus^ Crowe’s, in rheumatoid

’arthritis .. .. .. .. 126

Starch baths in psoriasis . . . . . . 464

— digestion in intestine . . .. 235

Starvation of dj’spnoea .. 166

Stasis, intestinal, complicating appendi-
citis . . . . . . . . . . 1 16

x~Ta.y diagnosis of . . . . . . 41

— peripheral .. .. .. .. 54S

State medicine 673

Static electricity as aid to hypnotism . . 561

— wave current in acute fibrositis . . 240

Steam, medicated, in asthma of children 130
Stegomyia mosquito and dengue . . 499

in etiology’ of 3’ellow fever . . 669

Stenosis of larynx following diphtheiia . . 331

— pjdorus, congenital . ‘ , 474

Sterilbiation, formaldehyde in . . . , 10

— of hands, etc., chlormetacrcsol for . . 6

— hj-drogen peroxide in. . . . , . 13

— of instruments, new appliances for 689

— of skin, alcoholic paste of kaolin in . . 14

alcoholic solution of iodine for . . 14

— water, ultra-violet radiation for . . 55

— women, radiation in . . , . . . 65

Sterilizers for dressings and instruments,

improvements in 716

Stethoscope, improved . , . . . . 71S

— use in suspected malingering . . 360

Still’s diseasCj identity with rheumatoid

arthritis 123

Stimulant effect of silver arsenke . . 4

Stokes-Adams sjmdrome {see Heart BlocJi) 2S9 j
Stomach, acute dilatation of . . . . 555 )

Stomach, cancer of 549

analysis of duodenal contents in 412 !

— cvacuator, new designs . . 718, 719 {

radiotherapy in . . . . . . 531

results of surgical operation . . 552

— dilatation, post-operalivc . . . . 302

— diphtheria of , . . . . . . . 209

— diseases .r-ray diagnosis of . . . . 40

Stomach and duodennm, sxir-

g-ery of .. .. •. .. 550

intussusception of . . .. .. 555

Stomach, fibromatosis of . . 556

— hair-ball in, .r-ray diagnosis of . . 40

— hour-glass 555

— lesions, relation to spinal deformity 530

— new apparatus for radiogiaphj' of 40

— volvulus of . . , . . . . , 554

Stomatitis, salvarsan in . . . . . . 27

Stomoxy’s calcitrans in etiology of pellagra 421
Stone {see Calculus)

Stovain ancesthesia in prostatectomj’ . . 460

— in spinal analgesia . . . . . . 108

Strabismus 556

— Harman’s new operation for. . . . 556

— partial tenotomy for . . . . , . 557

Straight-work exercises in lateral spinal

curvature . . . . . . . . 537

Strains, massage after . . . . . . 16

Strangulated hernia {see Hernia) . . 390

in infants . . . . . . . . 290

PACE

Strentococcal infection, sensitized vaccines
‘in 37

— origin of otitis media . . . . . . 395

— origin of pruritus ani. . . . . . 115

— origin of sinus thrombosis . . . . 407

— vaccines in rheumatoid arthritis . . 126

Streptococcus, association with ulcerative

endocarditis . . . . . . 325

— p3’'ogenes in cerebrospinal fluid , . 189

— vaccines, value of . . . . . . 34

Streptothricosis, operation for . . . . 348

— simulating phthisis . . . . , . S6

Strontium bromide in Graves’ disease , . 264

Strophanthin, elimitation from tissues of S
Strophanthus in auricular flutter . . 132

— cardiotonic action of . . . . . . 131

— in croupous pneumonia . . . . 442

— effect on paroxysmal lach\*cardia . . 2 85

— specific action on heart muscle 283, 284

Stricture of oesophagus . . . . . . 388

— ureter . . . . 650

— urethra . . . . . . , . . , 652

Str5'chnine, action on heart of . . . . 2S4

— injection preceding tuberculin . . 73

Subclavian aneun*sm , . , . . . 112

Subconjunctival advancement for squint 556

Subdeltoid bursitis, aspiration in .. 171

Sub-glottic oedema, post-bronchoscopic 170
Sugar as application to w’ounds and

ulcers , . . . . . . , 30

— in blood, method of estimating . . 149

— heart disease . . . . . . . . 2S3

— legal decision on description of . . 677

Sugar-free diet in diabetes . . . . 202

Suggestion in therapeutics, indications

and contraindications .. .. 564

Suggestion in therapeutics : its

legitimate uses .. .. 55S

metliod of procedure .. .. 559

Sulphate of sodium in functional derange-
ment of the liver . . . . 343

intestinal dj'spepsia of children.. 216

Sulph-hasmoglobinaemia . . . . 5^7

Sulphur as adjuvant in mercurial medica-
tion . . . . . . . . . . 5S1

— baths in psoriasis . , . . . , 464

— new method of applying to skin . . 30

— ointment in eczema * . . . . . 221

keratodermia blennorrhagica . . 310

— properties of . . . . . . . . 509

Sutyhur-containing oxyproteids in urine

in cancer .. .. ,. .. i8c

vSixlphuric acid in furunculosis . . . . 254

Suinbul, unfavourable results of use . . 31

Sunshine treatment of surgical tuberculosis 637
Sunstroke, differentiation from heat

exhaustion . . . . . . . . 290

Suprarenal extract in Graves’ disease . . 264

of little value in enuresis . . . . 229

pernicious vomiting . . . , 45 0

— — scarlet fever . . . . . . 501

— gland, irradiation for arterial hyper-

tension . . . . . . ' . . 48

Suprapubic drainage in cancer of prostate 463

— prostatectomy, method . . . . 459

Suppression of urine in blackwater fever 139
Surgery of the biliary tract . . . . 136

— bladder . . . . . . ..139

— brain . . . . 155

— breast . . . . , . . . ..160

— in epilepsy .. , .. .. 159, 330

— of gangrene . . . . . . . . 254

— geyser for . . . , . . . . 699

— heart . . , . . . . . . . 386

— intestines . . . . . . . . 302

— kidney 3ir

— knee . . . . 321

— in lab3Tinthine vertigo . . . . 666

— leprosy ■ . . . 334

CXVl

GENERAL INDEX

PAGE

,'-'urgery of liver . .

. . 341

“ lung

. . 344

- - nasal accessory sinuses

•• 371

— nerve roots ' . .

. . 524

— nose

. . 380

— iTcsophagus

. . 387

— pancreas

.. 413

— penis

. . 428

— prostate

. . 458

— rcctnm , .

. . 478

— in rheumatoid arthritis

. . . 126

— • of spinal cord

.. 519

— spleen . .

• • 543

— stomach and duodenum

. . 550

— thyroid gland

263, 605

— urethra . .

.. 651

— uterus . .

. . 662

— in visceroptosis

. . 667

Surgical instrument, sterilizing

'uses . . 689

— and medical appliances

. . 6S0

progress, review of

— operations, post-operative complica-

tions . . . . . . ..391

— tuberculosis (see Tu]-)erculosis) . . 636

Svtspension laryngoscopy . . .. .. 32 8

Stispensory bandages, improved . . 719

Suture of blood-vessels . , . . . . 120

— epiglottic, modified instrument for . . 329

— of kidney . . . . . , . . 320

— and ligature spool-attaclnnent . . 719

SntTires 567

— improved sterilizer for . . . . 718

Suturing forceps, new designs in . . 697

Svvimming-batli conjunctivitis . . . . 196

Sycosis, ionic medication in . . . . 59

~ vaccine therapy in 512

— r-rays in .. .. .. 513

Sympathetic, caffeine as stimulant of . . 5

Syncope in artificial pneumothorax . , 447

Sjmovitis, malingerers and . . . . 357

Syphilis 5^s

— of brain, operation in 155

— a cause of intermittent limp . . . . 122

Syphilis, cerebrospinal . . . . 586

diagnosis . . . . . . . . 586

treatment 589

— - “ chronic intermittent ” treatment . . 575

Syphilis, congenital .. 5S1, 597

gold chloride test for . . . . rgo

— diagnosis 570

— of the ear . . . . . . . . 21S

— etiology.. .. .. .. 568

— in etiology of thoracic aneurj-sm .. loS

— general review of . . . . . . 83

— Government action concerning . . 676

— of heart and aorta . . . . . . 375

— and heart-block . . . . . . 2SS

— influence on infant mortality . , 597

— leucocj'tosis in diagnosis of . . . 148

— of the liver . . . . . . , . 344

— and mental deficiency . . . . 596

— of mouth and throat’ salvarsaii in . . 3S4

— ocular, guaiacol diaphoresis in . . 234

— in pregnant women, treatment . . 583

— prognosis of heart disease . . . . 2S0

— relation to abnonnal .r-ray reactions 49

diabetes insipidus. . . . , . 200

mediastinal tumours . . . . 364

pernicious anaemia . . . . 100

~ — yaws 668

— salvarsan in (see also Salvarsan) 5 73 et seq.

— treatment . . , , . . . . 573

Syphilitic arthritis (see Arthritis, Sy-
philitic) .. .. .. 127

— nervous disease, increase of chole-

sterin in blood in . . . . , . 149

— stricture of oesophagus . . , . 3S9

— treatment in angina pectoris . . . . 114

— ulcers, simulated by blastomycosis.. 147

Syringe forceps, new debign . . . . 720

— for ureteric cathetei's . . . . 719

Si'riuges, hypodermic, new designs in . . 701

Syringomyelia, A'-ray treatment. . .. 4g

Systolic bruit, incidence of . . . . 279

T hompson, a. h., 183, 104, 198,

^33, 259, 306, 327, 483. 488, 556 ;
Tucker, B. R.j 424

Tabes, aleudriii in painful crises of . . 3

— results of salvarsan treatment . . 592

— (see Syphilis, Cerebrospinal).. .. 586

— Wassermann reaction in . . 572, 587

Table waters in arteriosclerosis . . . . 122

Tachycardia, paroxysmal .. .. 28$

— with rheumatoid arthritis . . . . 124

Talc, berated, in moist dermatoses .. 510

Tansy, oil of, small emmenagogue value of 0
Tape-worm in a case of peritonitis . . 432

Tabagan in relation to plague . . . . 439

Teeth, carious, in etiology of gastric

cancer . . . . . . . . <549

Telangiectatic granuloma . . . . 154

Temperature, effect of pituitary body on 433
— subnormal, in acute infections . . 640

Tenotomy, partial, for squint . . • . . 357

Test breakfast in gastrogenic diarrha'a 206
Test-meal findings in gastric ulcer . . 257

— -tube holders and stands, new designs 720
Testicle, inflammation of, in children . . 394

Tetanxis 599

— antitoxin . . . . . . . . 603

— general care of patient in . . . . 605

— preventive treatment 603

— treitment . . 604

Tetany after thyroidectomy, treatment

264, 606

Theobromine in angina pectoris . . . . 114

— with squill in dropsy . . . . . . 30

Thcocin in heart disease . . .. .. 285

— sodium acet.ate in cardiac rheumatism 282
Therapeutic progress, review of . . . . i

Thermo-cautery in fibrositis . . . . 239

Thenno-precipitin reaction in phthisis. . 623

Thermotherapy in gonorrhoeal arthritis 269
Thiersch skin grafts after removal of

breast . . . . . . . . 163

for urethral defects . . . . 651

Thigenol, a new suJplio-oleate .. .. 732

Thiocol, a new guaiacol compound . . 732

Thiosinamine in bums of the oesophagus 3S(j
Thomas’s knee splint for fractured femur 2 1.4
Thoracic aneurysm (see Aneurj'sm)

— diseases, doubtful, bronchoscopy in 170

Thorax, injuries of, indications for opera-
tion 347

— operations in (sec Lung Surgery)

— .i-ray diagnosis of lesions in . . . . 42

localization of foreign bodies in. . 167

Tborium 60

— therapeutic ap;plication . . . . 65

Thorium- tr in pernicious anaemia . . 100

Thread-worms caiising appendicitis .. 116

Tbread- worms to prevent re-infection

with 605

Three-day fever (see Sand-fly Fever)

Throat, cancer of, radiotherapy in . . ^

— irritation, thymacetol in ' . . •. . 31

— and nose diseases, review of . . . . 82

Throat and nose, greneral thera-
peutics of 383

— operations, pituitrin in lessening

’ heeraorrhage after. . . . . . 23

j Thrombophlebitis, post-operative . . . 392
1 Thrombosis of lateral sinus . . 407

I — post-operative prevention -)f • 393

I — of vena cava inferior.. .. G65

1 Thymacetol, a new thymol dem^ative. . 31

Tin me, oil of, small emmenagogue value of ’ 9

GENERAL INDEX

CXVll

PAOE

Thymol derivatives, ne’v\’ . . .. .. 31

— in goitre .. .. .. 262, 606

— hookworm disease . . . . . . 650

Th ymotinic acid, a new thymol derivative 3 1
Thvmus-giand extract in Graves’ disease 264
— ' — relation to sexual glands. , . . 515

— role of, in Graves’ disease . . . . 610

Thyroid disturbances, Abderhalden’s

dialysis test in .. .. ..iso

— extract in arteriosclerosis . . . . 122

enuresis . . , . , . . . esg

fibrosi+is . . . . . . . . 241

gonorrhceal arthritis . . . . 269

psoriasis 464

retinitis proliferans . . . . 234

skin diseases .sr5

tetan^’ after tlix’-roidectomy . . 606

Tliyroid g-land, surgery of . . 605

— medication in epilepsy . . . . 230

— preparations in tinnitus . . . . 613

— relation to pituitarj^ body . . . . 515

Thyroidectomized horse serum . . . . 732

Thyroidectin disappointing in Graves’

disease . . . . . . . . 264

Thyroidectomy, calcium lactate in tetany

after ’ . . . . . . . . 264 I

Thyroiditis, acute non-suppurative 6tr |

— parasitic . . . . . . . . 261

Thyrotomy for cancer of larimx . . . . 330

Tibia, fracture of spine of ..321

Tic douloureux, high-frequency currents

for 53

— {see Neuralgia, Trigeminal) 377

Tick fever {see Spirochaetosis) . , . . 541

Tics, suggestion treatment for . . . . 565

Time association in psycho-anal vsis . , 563

Tinea, cuprakrol a copper preparation

for . . . . . . . . . . 726

Tinuittis 612

— hysterical, suggestion treatment in,. 565

Tobacco in etiology of intermittent limp 122
Tongue, cancer of . . , . 614

Tongue, marginal resection of 614
Toe, great, swelling and redness in rheu-
matism in childhood . , . . 493

Tongue depressors, new designs . . . . 720

Tonics in pellagra . . . . . . . . 418

Tonsil instruments, new designs in 720, 721
Tonsillar operations, complications after 619
Tonsillectomy, technique of . . . . 617

— and tonsillo tom}*, relative value . . 6r6

Tonsillitis, association with erythema

nodosum . . . . . . . . 2 32

Tonsils O16 \

— tlie avenue of infection in rheumatism j

in childhood . . . . aQ2, 4.94 |

— enlarged, in etiology of otitis media 401 |

,v-ray treatment of . , . . 40 j

— site of prunary lesion in tuberculosis 1

of childhood .. .. .. 623 j

Torticollis congenital .. fiiq j

Toti’s operation for nasal duct obstruc- I

tion . . . . . . . . . . 327 j

Toxtemias of pregnancy . . . . . . 455

Toxicology and industrial dis-

* eases os 3

Toxicosis, manganese . . . . . . 687

Trachea, bronchoscopy for foreign bodies

in . . , . . . . . . . 167

Tracheotomy in acute non-suppurative

thyroiditis . . . . . . , . 612

— laryngeal tuberculosis . . . . 330

Trachoma, carbon dioxide snow in 233, 513

— ionic medication in . . . . . . 59

Traction with operation for fracture , . 244

Trade union funds, immunity of . . 670

Trades directory . . . . . . . , 7S3 1

Transfusion of’ dedbrinated blood in

severe ancemia

P.4.GE

Transfusion in heemorrhages of the newiy-

bom .. '.. .. 273

Transverse colostomy, advantages of . . 303

Traumatic neurasthenia . . . . . . 379

malingerers and . , , . . . 360

Treatment, dictionar}’ of . . . . 77

Trephining sclero-comeal limbus for

glaucoma . . , . . . .,23c

— suggested in neurasthenia . . . . 3S0

I — for traumal ic epilepsy . . . , 230

Tridiocephalus dispar a cause of appendi-
citis. . . . . , . . ’ . . 117

Trichomonas intestinalis as cause of
I dysentery .. .. ..213

j Trigeminal neuralgia (see Neuralgia Tri-
geminal . . . . . . . . 377

high-frequency cunents in . . 55

Trinitrin in angina pectoris . . . , 114

Trioxymethylehe as a disinfectant . , 10
Trixidin in sleeping sickness . . . . 621

Trophoederaa, IMilroj-’s, relation of “ blue

brain ” to . . . . . , . . S4vS

Tropical diseases, general review* of . , 83

— splenomegaly, identity of infantile

infective anseniia with . . . . r,6

Truss, adjustable elastic., .. .. 721

Trj’panocide, trypasafrol as a . . . . 32

Trj'panosoma gambiense, action of galyl

and ludyl on ,. ., 5S0

Trypanosome causing thyroiditis . . 261

Tr>*panosomes, new varieties of . . . . 619

Trypanosomiasis C19

Tr^’pasafrol as a trj'panocide . . . . 32

Tr3'psin in duodenal contents in pan-
creatic and gastric diseases 412, 413
Tubal pregnancy . . . . . . . . 455

Tubercle bacilli, staining methods . . 622

— of brain, operation for . . . . 153

Tuberculin, adverse opinion of . . ... 34

— analysis of results of treatment . . 74

— cases, new designs . . . . . . 722

— in conjunctival tuberculosis . . . , 195

— dangers of 74

— in dementia paralytica . . . . 5S9

— diagnosis . . . . . . . . 70

j — dispensaries, growth of . . . . 74

i — dosage of . . . . . . . . 75

— effect on blood of , . . . . . 73

— I. K 72

— injections, new syringe for . . . . 70 r

— raitigatum ointment . . . . . . 73

— old, In lupus vulgaris. . . . . . 512

— outfits . . . . . . . . . . 732

— reaction in epidemic pneumonia . . 444

— in renal tuberculosis .. .. .. 31$

— Rosenbach . . . . . . . . 71

— with sanatorium treatment in phthisis 634

— in surgical tuberculosis . . . . G37

— tests, importance in tuberculosis in

childhood . . , . . . . . 627

— theory of action . . . . . . 68

Tuberculin therapy .. 6 S

— in tuberculosis in childhood . . 62 S

of the skin.. .. .. ,. 516

— variety to be used . . . . . . 72

Tuberculo-muciu, Weleminsky’s . . 72

Tuberculosan-Burow' .... . , 72

Tuberculosis, artificial pneumothorax in 445

— borcholin in . . * . . . . . . 4

— of bronchial glands . . . . . . 162

— in causation of erythema nodosum . . 233

— formaldehyde inhalants in .. .. 72 S

— sanatoria for . . . . . . . . 76 r

Tuberculosis iu childhood .. 623

diagnosis . . . , . . . . 626

etiology .. .. ,. .. 623

general re\*iew of . . . . . . 78

site of primary lesion . . . . 625

sources of infection . . . . 624

GENERAL INDEX

PAGE

627

622

195

394

149

329

330

368

675

Tuberculosis in childlmod, treatment ..
Tuberculosis, clinical patbolog’y
of

— of the coniunctiva

— in etiologj’ of orchitis in diildren .. .

— of glans penis .. .. .. .. 42S

— gold combinations in. . .

— increase ot cliolesterin in blood in . .
of lar5"nx, suspension larjmgoscopy in

treatment ..

— “ mesbe ” in treatment of . .

— of mesenteric glands . .

— in milk, Board of Agriculture Order re

— notification of . . , . . . - . 674

— oxygen injections in acute asphyxia

due to

Tuberculosis, pulmonary

abortive type of . .

albumin test of sputum in

Ameth blood count in

bronchoscopy in . .

— - — diagnosis

misuse of term “ influenza " in . .

simulated by actinomycosis

— » — treatment . .

by collapse

A*-ray diai^osis of . .

— relation to diabetes . .

— renal {see Kidney, Surgery* of)

dysuria in . .

— of the skin

— sohdification of lung in surgery of . .
Tuberculosis, surgrical

— surgical, dioradin in . .

— — etiology

234

365

441

684

— :^-tf>tirve3’' of tuberculin treatment in . .
'-Tuberculosoid cases
Tuberculous hygroma, action of carben-
zynne on

— iritis’ hetol in

— joints, etc., allyl sulphide in . ,
Tuberculous meniu&itis . .

— pleurisy, serofibrinous effusion injec-

tions in

— pork, legal decision re warranty . .
Tubolytin, watery extract of tubercle

bacilli

Tiifnell's treatment of aortic aneurysm
Tumours of the bladder . . . . . . 139

Tumours of tbe brain . . - ■ i55

results of operation . . . . 156

— effect of radio-active substances on. . 65

removal on glycosuria . . . . 205

— endosteal, .v-ray diagnosis of . . - . 43

— of the kidney . . . . . . . . 318

— larynx, susp'ension larj'ngoscopj' in . . 329

— spine . . . . 519

Turbinals, inferior, ner\’'e supply of • . 380

Turpentine for expulsion of renal calculus 315

— oil of, small emmenagogue value of . . 9

— in psoriasis . . . . . . . . <.64

Tvvitdiing, diaracterislic, in epidemic

poliomyelitis

Tjdcalsin and tyllithin, aceto-salicylates
of calcium and lithium . .

Tympanites, pituitary extract in

— post-operative, urotropin in . .

Tympanum, spontaneous re-formation of
Typhlitis, fermentative, oxygen insuffla-
tion for

Typhoid carriers . .

— — removal of gall-bladder in

Typhoid fever

causes of weight -loss in . .

colloidal silver iu . .

diagnosis . .

diet in

etiology . .

451

732

400

639

646

638

643

640

843

63S

Tvphoid fever, haemorrhagic syndrome in
_1 — occasional low temperature in , .

prophj’laxis

relation to paralsphoid . ,

symptoms . .

treatment

— nzara in diarrhoea of

— spine

— vaccine, results of administration . .

Typhus fever .. •• •*

identity of Bull’s disease with . .

Tyramine, cock’s-comb test of . .

— therapeutic action of . .

Tyrosin in pathology' of cataract

U PCOTT, H., 84, 85, 11=3, 136, 29 --i,
302, 341, 368, 412, 430, 432, 543»
550

Uebergangsformen, or splenocytes
Ulcer of duodenum in childhood
— fibromatosis of stomach
— gastric {see Gastric Ulcer)

— peptic, of oesophagus . .

— simple solitars', of bladder . .

— varicose, cure by cream -dicese
application . .

TTlcers .. .• c*‘

— adhesive plaster as direct dressing lOr
— carbon ^oxide freezing in
— of cornea, scarlet red in
— ionic medication in . .

— sugar as application to
— thymacetol in dressing of . .
Ulceration, intestinal, character of fseces
in . . . . ^ .

Ulcerative sporotrichosis . .

Ulna, fracture of, with dislocation of
head of radius

Ultra-violet rays in alopecia areata

bactericidal properties of . .

Umbilical hernia, modified operation tor
XTmbilical infection, in the new-
born

XTneinariasis

Ung. chinin. camphorat. co. to prevent
re-infection with thread-worms . ,
Urtemia, oxygen inicetions in asphyxia
from . .”

— post-choleraic . .

— a terminal event of arterial liyper-
tension

Urea hydrochloride and quinine in major
surgeiy . . . . ,

— and quinine in pneumonia . .
Ureabromine a useful sedative . .

Ureteral calculus, oil injections for
Ureteral obstruction
Ureteric catheters, silk web
— * — syringe for . .

Urethra, double

Urethral defects, Thiersch grafting for. .
Urethral diseases . . ....

— raucous membrane, anccsthetizing
effect of potassium permauganate

— stricture • •

Urethritis, gonorrhoeal {see Gonorrhoea)
Urethrorrhapliy, technique of . .
Urethroscopy in gonorrhcea
Urethrostomy after resection of urethra
Uric acid excretion, action of acitrin on

output, effect of radium substances

on .. '

Urinals, improvements in
Urinarv an&eptic. hexal as a . .

— antiseptics

in cancer of prostate

experiments on relative value o!

in gonorrhoea

639

640
<•45

414

939

G42

639

G45

847

647

isl

335

305

55<>

235

390

146

64S

514

236

540

253

55
29 1

648

649
605

194

153

ro4

4LS

650

ftso

Omc

710

851
65 X

651

<353

267

653

654

463

207

GENERAL INDEX

CXIX

Urinary complaints, seminal vesiculotomv

for . . . . . . . ' ;

in women . . . , , . , . 3

— fistulas after perineal prostatectomy (

Urinary incontinence in women <
Urinary infections i

— inflammations, agmel for . . - . ;

— surgery, general review of . .

Urine, Bence-Jones’ protein in , . . . .

— Bumam’s test for formaldehyde in . .

— diastase in, in interstitial pancreatitis .

— examination in pyelitis of children . . .

rheumatoid arthritis . . . . ;

— fomraldehj-'de in, after urotropin 12, <

— specimen glass, improved . , . ,

— suppression of, in blackwater fever. .

Urine tests 1

in diagnosis of cancer . . . , :

— tubercle bacilli in . . . . . . (

Urino-genitary operations, spinal analgesia

in . . . . . . . . . .

Urobilin in urine in malaria . . , . ;

Urotropin, action as urinary antiseptic . .

— in cerebrospinal fever . . . .

— cirrhosis of the liver . .

— effect on urine of general paralj'tics

— in enuresis

— excretion in pus

— formaldehyde in urine after.. 12,

— in goitre

— otitic menhigitis . . . . 401,

— pellagra . .

— pyelitis of children . ,

— test for formaldehyde in urine after

— therapeutic indications for . .

— in typhoid fever

— urinary infections

Urticaria

— human blood in

— pituitary and suprarenal extract in

— ^•accine-therapy in

Uterine abnormalities, Caesarian section for

— contraction, synthetic hydrastinin in

— disorders, suggestion treatment in . .

— hsemorrhage, erystypticin in
renaglandin tampons for

— mucosa, radiotherapy in epithelioma of

— myoma, radiation in . .

— . — ,r-ray treatment of
Uterus, cancer of ..

radiation in

A--rays and radiiun in , . 46,

Uterus, 'diseases of
Uterus, displacements of

— rc.pture ot, after adminibtratiun of

pituglandol . .

Uva ursi as a urinary antiseptic , .

in urinar3" inlections

Uveal tract, diseases of . .

Uzara, use in controlling diarrhoea

T JON NOORDEN, C., 60

V ‘Vaccination

Vaccination and cerebrospinal fever . .

— against tuberculosis . .

— stations, educational . . . :

Vaccine tlierapy in actinomA’cosis
acne

acute rheumatism . .

cardiac rheumatism

clironic bronchitis and asthma . ,

enuresis

gonorrhoea . . . . 267, 26S,

ligneous i^hlegmons

otitic meningitis . .

pemphigus . . . . . . 427,

pertussis

plague

pruritus ani

PAGE

Vaccine tlierapy in sprue . , . . 547

rheumatism in childhood . . 495

— - — rheumatoid arthritis . . 124, 126

septiceemia . . .. .. .. 505

skin diseases . , . . . . 511

tj'phoid fever . . . . . . 642

efficacj’' of . - . . . . 645

ulcerative endocarditis . . , , 227

uveitis . . . . . . . , 308

Vaccines . . . . . . . . 33

of little use in p^'elitis ol children 474

nose and throat ’catarrhs . . 3S3

— new “ stock ” . . . . . . . . 732

— sensitized . . . . . . . . 37

relative safety of . . . . . . 3S3

Vaginal clamp for hj'sterectom}* . . 693

— douche tube, new design ., 694

— haemorrhage at menopause, import-

ance of education re . . . . G61

— mucosa, radiotherapy in epithelioma

of 5r

Vaginal sarcoma 664

— walls, operation in collapse of . . 663

Vaginitis, ionic medication in . . , . 59

Valerian in phrenocardia . . . . 229

— tinnitus.. .. .. .. .. 613

Valvular disease, prognosis , . . . 2S0

Vaporizer, improved design . . . . 723

Vapour baths in rheumatoid arthritis . . 125

Yaquez’s disease .. .. .. .. 453

Varicose ulcer, cure by cream-cheese

application.. . .. .. 64 S

— veins . . . . . . . . . . 665

Vascular anastomosis . . . . , . 120

Vas deferens, radiography of 44

Vasomotor phenomena of rheimiatoid^

arthritis . . . . . . . . '

Vasostomy for chronic seminal vesiculitis 504 -
Vegetarian diet in angina pectoris . . 114

psoriasis . . . . . . . . 464

Vein grafting after excision of aneurj'sm lao
Vena cava inferior, thrombosis

of 665

Venereal diseases, general review of . . S3

Government action on . . . . 676

Venesection in croupous pneumonia . . 442

— typhoid fever . . . . . . . . 641

Ventilation in prevention of heat exhaus-
tion . . . . . . . . . . 290

Ventrofixation for displaced uterus . . 663

Veratrone in eclampsia . . . . . . 456

Veratrum viride in eclampsia . . . . 457

Verruga peruana - . . . . . 666

Vertebral spines, auscultation over,
in diagnosis of tuberculotis bron-
cliial glands . . . . . . 163

— tumours . . . . . . . . 520

Vertigo 666

Vesical disease (sue Bladder)

Vetcrinarx* Surgeons Act, decision under 685
Vibrion septique as cause of gangrene . . 255

Vinegar adulteration, legal decision re. . 677

Violet raj’S in alopecia areata . . . , go

Virus of epidemic poliomyelitis . . . . 450

— rabies, culture of . . . . , . 476

Visceral crises, Franke’s operation for. . 526

resection of nerve roots for , . 524

— lesions, relation to spinal deformitj- 529

suggestion treatment in . . . . 566

Visceroptosis 667

Vision, statistics after operation for

cataract . . . . . . . . 183

Vitreous opacities, guaiacol diaphoresis

in 234

Volkmann’s paralysis (s£e Mj’ositis,
Ischsemic)

Volvulus of stomach . . , . . . 554

Vomiting of pregnancx’ . . . . . . 4.*; 6

— nervous, suggestion treatment in . . 566

GENERAL INDEX

PAGE

Von PirqneL’s reaction in epidemic pncu-

nionia . . . . . . . . 444

in tuberculosis in childhood.. 627

Von Ruck’s tubercle extract . . . . 72

Vulvitis as cause of enuresis . . . . 22S

W ALKER, J. W. T., 139, 31 1, 45S,

503, 650, 651

Warts, carbon dioxide snow for . . .. 513

— ionic medication for . . . . . . 59

— mesothorium for .. .. .. 514

Wassermann reaction (sec Syphilis) .. 571

called for in angina pectoris . . 114

in cerebrospinal syphilis.. .. 587

compared with complement*fixa-

tion . . . . . . . . 265

in congenital keratitis and deafness 218

syphilis 598

diabetes . . . . . . . . 572

diabetic acidosis . . . . . . 204

negative in sporotrichosis . . 546

in sj'philis of heart and aorta . . 276

Water injections, healing of syphilitic

ulcers after. . .. .. 5 78

-T sterilization, ultra-violet radiations

for 55

— supply, ill etiology of goitre . . . . 260

legal decision re . . . . . . 685

— • — in urticaria 659

Wax, impacted in ear, causing severe

cough 199

Weaning, unnecessary 297

Weavers (cotton), unusual fontn of illness

among.st 687

Weber’s test in prognosis of otitis media 399
Weight loss, causes of, in typhoid fever 643
— reduction in stout broncnitics . . 166

— traction in contraction ring , . . . 325

Weil’s disease, distinction from catarrhal

jaundice . . . . . . . . 300

Weleminsky’s tuberculo-mucin . . , . 72

Wermolin, a new w'ormseed oil prepara-
tion . . . . , . . . . . 37

Wertlieim’s panhj’sterectomy, clamp for 693

modification of . . . . . . 660

West’s operation for nasal duct obstnic-

tiou 327

Wlieelhouse operation for stricture,

modification of . . . . . . 652

Wliitlow in causation of osteomyelitis of

spine 541;

Whitman’s abduction method in fracture

of femur .. .. .. 251

Whooping-cough (see Pertussis) . . . . 433

Widal reaction in typhoid fever. . . . 641:

typhus . . 647

Wild game in etiology of sleeping sick-
ness.. .. .. .. .. 620

Wilms’ method of perineal prostatectomy 460
— operation of rib mobilization . . 348

Wintergreen oil in rheumatoid arthritis 125
Wolgemuth’s method of estimating

diastase in faeces 411

Women, incontinence of urine in .. 654

Workmen’s Compensation Act, decisions

under . . . . . . . . 671

Workers and industrial anthrax infection 687
Worms, intestinal, causing appendicitis 116
Wonnseed oil, new method of administer-
ing 37

Wounds of abdomen, gunshot . . . . 84

— adhesive plaster as direct dressing for 514
— atonic, incandescent light in . . 55

PAGE

Wounds of the heart . . . . . . 286

— iodine as sole dressing to dean . . 14

— of lung, indications for operation . . 3^17

treatment . . . . . . . . 348

— noviform in dressing of . . . . *^19

— picric acid for . . .. .. .. 22

— sugar as application to . . , . 30

— thymacetol in dressing of . . . . 31

Wrist, fractures about . . , . . . 252

Wrist-drop, exercises for. . . . . . 17

Writer’s cramp, suggestion treatment and 565

^ -RAY apparatus, new . . . . 39

-A. — rotary high tension . . 72 5

X-ray diagnosis '39

of bony conditions . . . . 43

cardiospasm . . . . . . 390

dystopic kidney .. .. 312

ethmoidal disease.. .. .. 328

gastric diseases . . . . . . 40

and duodenal ulcer . , . . 258

hour-glass stomach . . . . 555

kidney diseases . . . . . . 44

laryngeal disease 32 8

liver diseases 39

oesophageal cancer . . . . 387

otitis media , . 396

renal calculi .. .. 314. 315

thoracic aneurysm .. no

lesions . . . . . . . . 42

tuberculosis in childhood. . . , 626

bronchial glands . . . . 163

typhoid spine 639

vesical tumours 139

— localization of foreign bodies in thora.x: 16S

— reactions, precocious 49

X-ray treatment 45

A-rays in alopecia areata . . . . go

— anaemia in children 97

— arterial hypertension 154

— artificial pneumothorax . . 446, 448

— Darier’s disease .. .. 3fr

— disappointing in lupus erythematosus 350

— in eczema . . . . . . . . 220

— epithelioma of skin . . . . . . 507

— experiments in filtration of . . . . 45

— in inoperable cancer of stomach . , 554

— leukaemia . . . . . . . . 337

— Icukcemic eruptions , . . . . . 340

— and radium, comparison of in cancer ' 4O

— in skin diseases . . . . . . 513

general principles for adminis-
tration 514

— study of constipation. . . . . . 197

— and the surgical anatomy of the

colon . . . . . . . . 478

— surgical tuberculosis . . . . . . G38

X/'AVITA’S metliod of demonstrating
1 ova in fieces . . . . . 230

Yaws 668

— luetin reaction in . . . . , . 571

Yellow fever 669

— ointment in phlyctenular conjuncti-

vitis . 195

— oxide of mercuiy ointment, new

preparation of . . . . . . 732

Young’s operation for prostatic bars and

contracture 461

Z INC oxide in otitis media . . . . 400

— salts in lupus erythematosus . . 3^0

— sulphate, ionization with .. 56

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List of Illustrations

PLATES

PAGE

Plate I. — Gall-stones isktagram) • • • • 39

Plates II, III. — Hair balls in the stomach [skiagvann . . 40-1

Plate IV. — Amcebiasis {Loloitved) ..... 91

Plate V. — Botryomycosis . . . . .154

Plates VI, "\"II. — Halsted’s method of grafting after excision of

breast ....... 1^2-3

Pl.^tes VIII to X. — Types of epithelioma . . . 176-7

Plates XI, XII. — Tyrosin and cholesterin in cataractons lenses . 1S4-5

Plates XIII to X\’. — Tuberculosis of the conjunctiva [colonred) . 194-6

Plates XVI, X\TI. — Fracture of the neck of the femur . -44-5.

Plate XVIII. — Whitman’s method of treating fracture of the neck

of the femur ....... 250

Plates XIX, XX. — Familial dystrophy of hair and nails . . -74~5

Plates XXI, XXII. — Umbilical hernia .... 292-3

Plate XXIII. — Brennemann’s experiments on curd formation . 299

Plate XXIV. — Intestinal surgery .... 303

Plate XXV. — Radiography of the larynx . . . 3'2‘8-_,

Pl.\te XXVI. — Killian’s suspension larymgoscopy . . 329

Plates XXVII, XXVHI. — Epithelioma of the oesophagus . 3S6-7

Plate XXIX. — Effective subdural drainage in temporal and cere-
bellar tumours (colotwed) ..... 406

Plate XXX. — Streptococcic meningitis {coloured) . . 406 ■

Plate XXXI. — Intracranial venous circulation {coloured) . 40S

Plates XXXII to XXXV. — Pellagra, as seen in America [coloured) 424-6

Pl.ate XXXVI. — [Metastatic nodules in long bones and skull {skia-
gram) ....... 464

Plates XXXVH, XXXVIII. — [Multiple myelomata (skiagrams) . 464

Plate XXXIX. — Clinical examination of puncture fluids (coloured) 46S

Plate XL. — Bacillus coli infection of the kidney {colon red) . 474

Plates XLI, XLII. — Retinal vascular disease . . . 4SS-9

Plates XLIII, XLI^^- — Rhinoplast}' — Hollander’s mellKHl . j{g6-y

Plate XL^'. — Intraspinal tumours . . . . 522

Plates XL^T to L. — Scoliosis ..... 331-7

Plate LI. — [Multilocular cyst formations in the spleen . . 543

Plate LIL — Sporotrichosis ..... 547

Plates Llll, LIV. — Sutures ..... 568-9

Plates LV to LX. — Luetin reaction in diagnosis of syphilis {coloured

and plain) . ^ . . . . . . 570-2

Plates LXI, LXII. — Eczema oris syphilitica {coloured and plain) . 597

Plate LX III. — Uncinariasis , . . . . 649

cxxiv LIST OF ILLUSTRATIONS

ILLUSTRATIONS

FIGS. PAGE

I. — Ionization with potassium iodide ... 56

j. — Ionization with zinc sulphate . . . . 56

3, 4. — Kelly’s apparatus for intratracheal anaesthesia . . 105

5. — ^Y-ray examination of intrathoracic aneurysm . . no

6. — Chronic appendicitis due to thread-worms . . 116

7. — Porta’s method of end-to-end suture of blood-vessels . 120

8. — -Rheumatoid arthritis, showing oedema of knee-joints . 124

9. — Diagram showing angulation of duct after cholecystostomy 13S

10. — Hudson’s appliance for drainage in operation for hydro-

cephalus . . . . . . 15S

11. — Haynes’ operation for internal hydrocephalus . . 159

12. — Caliper-guide for bronchoscopy . . . 167

13, 14. — Film of tracheo-broncheal tree to assist in location of foreign

body ....... 16S-9

15. — Lewisohn’s rectangular telescopic oesophagoscope . 170

16. — Aspiration in subdeltoid bursitis . . . .172

17. — Skiagram of patent ductus arteriosus . . . 213

18. — Activity of digestion in the intestine . . . 235

19. — Distribution of microbes in the intestine . . 236

20-22. — Hey Groves’ pegs in operation for fracture . . 247-8

23-30. — Whitman’s abduction treatment in fracture of femur . 24S-51

31. — Epiphyseal fracture of femur, indicating open operation . 232

32. — Diagrams illustrating the formation of cysts in hernial sacs 291

33-7. — Retrograde incarcerated hernia .... 292-3

38. — Operation for fracture of tibial spine . . . 323

39. — Horsford’s epiglottic suture forceps . . 329

40. — Muscles of forearm affected by ischa?mic contraction . 370

41. — Hartel’s method of injecting the Gasserian ganglion . 377

42. — Bone transplantation for nasal deformity . . 3S2

43. — Accessory pancreas in the jejunum . . . 413

44. — Dystrophia adiposogenitalis . . . . 43O

45. — Chart of pyelonephritis due to B. coli communis . 473

46. — Cultures of rabies virus . . . . 476

-47“-9- — Charts of rat-bite fever . . . . . 477

50-2. — Tests of near point in errors of retraction . . 4S4-5

LIST OF ILLUSTRATIONS

CXXA'

FIGS.

53. — Rhinoplasty, \vith skin flap from chest .

54. — Injection in sacral canal for sciatica

35. — Chart of case of septicaemia under vaccine treatment
56-7. — Extramedullar}" tumour of spinal cord
3S-9. — “Intramedullary tumour of spinal cord
*60. — Lower end of ligamentum denticulatum .

61. — Showing intimate relation of pleura to intercostal nerve
62-4. — Pseudo-fracture of transverse process of spine
65,— Plorizontal scheme of advanced scoliosis .

66-70. — Lateral curvature of spine : treatment by creeping exercises

71. — Diagram showing site of perforation in gastric and duodenal

ulcers .......

72. — Rayner Batten's fixation fork for operation for squint

73. — Harman's partial tenotomy for squint

74. — Harman's director -forceps for operation for squint .

75. — Shotted subcuticular suture . . .

76-80. — Marginal resection of tongue . . . .

Si-2. — Mechanic’s '' dog " for tonsil guillotine
83-1 86. — illustrating recent medical and surgical appliances

PAGE.
496.
5or
306
521.
522
326.
5-7
5^7-S'
530
5 3 --7

5.31^

5.57

557

55S

567

615

68 9-724

Index to Advertisers

PAGE

ACCOUNT BOOKS (MEDICAL)—

Doctors’ Accountaucv Bureau . . 806

Lewis, H. K 817

ACCOUNT CARD SYSTEM—

Bale, Sons & Danielsson Ltd. . . . , SoS

Reynolds & Branson Ltd. .. .. xxiii

ACCOUNTANTS (MEDICAL)—

Doctors’ Accountancy Bureau . . S06

AMBULANCE—

St. John Ambulance Association , . 848

ANATOMICAL MODELS—

Benninghoven . . . . . . . . S06

Apj^IFICIAL LIMBS—

#*’’'*'*critchley, J. & Sous . . . . . . 9.^0

Gardner, J*. & Son . . . . . . 931

Grossniith, W. R 932

Weiss, John & Son Ltd. . . .. 932

ASSURANCE OFFICES—
Australian Mutual Provident . .
Britannic Assurance . .

Clergy Mutual

Co-operative Insurance Society
General Life

National Mutual Life Association
Australasia

North British and Tkicreantile
Prudential

Wesle>’aa and General
Yorkshire

503
802

801
804

802

504
exxU

803
802
796

ASYLUMS, INSTITUTIONS, AND
HOSPITALS FOR THE MEN-
TALLY AFFLICTED—

Ashbrook Hall, HoUington . . . . 902

Ashwood House, Kingswinford . . 901

Bamwood House, Gloucester . . . . 900

Bethel Hospital, Norwich . . . . 895

Bethnall House, N.E. . . . . . - S92

Bootham Park, York . . . . , . S89

Boreatton Park, Baschurch . , . . 89 6

Bryn-y-neuadd Hall, Llanfairfechaii . . 89 1

Camberwell House, S.E. . . . . S99

City of Lo^idon Mental Hospital, near
Dartford . . . . . . . . 892

Clarence Lodge, Claphani Park, S.W. S99
Coppice, The, Nottingham . . . . 902

Coton Hill aiental Hospital, Stafford 902
Cranboume Hall, Jersey . . , . 903

Derby Borough Asyhmi, Rowditch . . 904

Dorchester Asylum, “ Herrisou ” . , 906

Famham House and IMaryville, Dublin 004

Grange, The, Rotherham . . . . 903

PAGE

Asylums — co nt i n u ed .

Hampstead, Glasncvin, and Highfield,
Drumcondra . . . . . . . . 904

Hendon Grove, Hendon, N.M'. . . 892

Holloway Sanatorium, Virginia IVater 898
Isle of V’ight Asylum . . . . . . 897

James Murray’s Royal Asylum, Perth qoi
JKingsdouTi House. Box, near Bath . . 894

Lawn, Lincoln . . . . , . . . 905

Littleton Hall. Brentwood . . . . 905

jVCddleton Hall, Middleton St. George 902
Moat House, Taniworth . . " . 896

New Saughton Hall, Polton, N.B. . . S93

Newlands House, Tooling. S.W. . . 900

Northumberland House, X. . . . . S98

Northwoods House, Winterbourne . . 901

Otto House, West Kensington, W. . . 900

Peckliam House, Peckhani, S.p. . . 897

Plympton House, South Devon . . 900

Portsraoutli Coriioration Montai HospitalSQa

Retreat, near Armagh 004

Retreat, Lancaster 896

Retreat, York 898

Royal Albert Institution, Lancaster.. 906
Shaftesbury House, Fonnby-by-Sea . . 89 3

Silver Birches, Epsom , . ' . . . . 90G

Springfield House, near Bedford . . 899

St. Andrew’s Hospital, Northampton Sgt
St. George’s Retreat. Burgess Hill . , 906

St. Luke’s Hospital, London.. .. S97

St. Mary’s Hou^c, Whitchurch . . 905

Stoke Park Colony, Stapleton (Children) qo6
Stretton House, Church Stretton , . S94

Throxenby Hall, near Scarborough . . 89 8

Tue Brook Villa, Liveqjool . . . . 905

Uplands, .Macclesfield . . . . . . 905

Wameford, The, Oxford . . , . 903

West Mailing Place, Kent . . . . 8 89

Wye House A'lylum, Buxton . . . . 890

AUTHORS’ MANUSCRIPTS—
Cambridge l,iterar}' Agenej- . . . . S14

BANDAGES—

{see “ Suigical Appliances”)

BATHS, SPAS, HEALTH RESORTS—
(see “ Hydro-therapeutic Establish-
ments,” Etc.)

BOOK ANNOUNCEMENTS—

(see page cxxxi.)

BOOKSELLERS—

Foyle, W. & G 806

BOOTS AND SHOES—

Freeman, John. . . .. ..934

Holden Bros. . . . . . . . . 933

INDEX TO ADVERTISERS

CXXVll

PAGE I

BRANDIES, WINES, SPIRITS, Etc. I
Bro\sn, Gore & Co.. Brandies Ixxxvi, 793 1
Gautier Freres’ Brandies . . Ixxxvi, 793 .
Rattraj’, A. Dewar, Whisk}' . . xxxvii J

BRASS NAME PLATES—

Sage, Frcdk, &, Co. Ltd. . . . . 924

PAGE

DIABETIC PREPARATIONS—

Emsson Jeune (Therapeutic Foods
Co.) . . . . , . . . cxxi

Callard & Co. . . . . . . . . 949

Pitman ” Flealth Food Co. . . . . 950

DRESSINGS—

{s^e “ Surgical Appliances,”)

CARRIAGES FOR INVALIDS— I

$t. John Ambulance Association . . S4S

CHEMICAL PREPARATIONS.
DISINFECTANTS. Etc.—

Allen & Hanbiir5-s Ltd. . . xlii, xliii

Alliance Drug & Chemical Co. . . xl

Bayer Co. Ltd... .. .. .. xlvii

Bresillon, AI. & Co. . . . . xxx\^iii

Browne & Saver, Sugar Test . . . . 935

Burroughs Wellcome & Co. . . Ixvi-bcxi
Chesebrough Mfg. Co. (Cons’d) xlviii

Chinosol Hygienic Co. . . . . . . 946

Clay, Paget & Co. Ltd 944

Denver Chemical Mfg. Co. . . . . bdv

Evans Sons Lescher & Webb Ltd. xlv
Fellows Syrup of Hj’pophosphites . . Ixi
Ferris & Co. Ltd. Back End Papers and 937
Formalin Hygienic Co. Ltd., Disinfec-
tants . . ’ xxiv

Giles, Schacht & Co. . . . . Ixxiv, 794

Handford & Dawson . . . . . . 950

Hewlett, C. J. & Son, Ltd. . . . . 946

Hoffmann-I^a Roche Chemical Work.s

Ltd 039

Hygienic Co. Ltd., Zana Baths xxxvi
Ingram & Roj'le Ltd., Natural Carls-
bad Sprudel Salt . . . . . . 943

Kerol Disinfectants and Antiseptics Ixxvi
Knoll & Co. . . . . . . , . xlix

Kuhn, B. & Co. .. .. .. 946

Lister Institute of Preventive IMedicine xliii
Mai tine Manufacturing Co. Ltd. . . ii
Martindale, W. . , . . . . . . lix

Medical Enterprise Society Ltd. . . xxxv
Oppenheimer, Son & Co. Ltd. . . xxxii
Parke, Davis & Co. . . . . . . 938

Phillips, Chas. H., Chemical Co. ..xxxiv j
Pneumosan Chemischc-Fnbrik . . x!iv j
Quibell Brothers Ltd., Disinfectants Ixxvi ]
Reynolds & Branson Ltd. . . . . xxiii 1

Riedel, The J. D., Co. . . . . 1, li i

Roberts & Co. . . . . . . . 947 i

Robin’s Laboiatorics . . , . . . Q45

Rogers, Frank A. . . . . . xxv

Saccharin Corporation Ltd. . , . . xlvi

S. P. Charges Co., Sulphatiua . .xxxiv
Stcclc it Marsh.. .. .. ,. 947

Sumner, R, & Co. Ltd. . . vii. xiii

Symes & Co. Ltd. .. .. .. 9^^

Wander, A. Ltd, . , . . . . exxi

W3.ssermann Institute. . .. xxxvii

MHiiffen & Sons Ltd. . . . . . .xxxvi

.Willows, Francis, Butler & Thompson

Ltd . . . 944

Woolley, James, Sons & Co. Ltd. . . 940

Wulfing, A. & Co., C\'Stopurin . . 941

Zimniermann, A. & 3M. . . xxxix, xli

Zimmermann, Chas. & Co. (Chemicals)
r,td. . , . . . . . , , . XXXV

DENTAL INSTRUMENTS AND
APPLIANCES—

Dental Manufacturing Co Ltd. . . 92S

Western Dental Mfg. Co. Ltd, . . 939

EDUCATIONAL INSTITUTIONS,

SCHOOLS, Etc.—

Barnardo’s (Dr.' Homes . . . . lx.xx

Colthurst House (Epileptic Boys) .. S57

Home Students College Ltd. . . . . S53

Kent Agricultural School . . . . S52

London School ot JNlassage . . , . 856

IVIedical Correspondence College . . 853

Normanslield, Hampton WTck (Mentally
Deficient) .. .. S61

Peile-Seyfang Scliool of Health Exer-
cises . . , . . . . . . . Iviii

Roj'al .-tlbert Institution, Lancaster
(Feeble Minded Children) , . . 906

Royal School for the Indigent Blind. . Iv
School for the Deaf, Northampton . . 85 6

School of Fencing and G^■lnnasil^n,

Bath ' . . . . S50

Stoke Pari: Colony, Stapleton (Mentally
Defective Children) , . . . . . * go6

Swedish Training School for ^Massage
and Remedial P'xercise.s . . Iviii

University Examination Postal Insti-
tution * . . . . . . . ' v . . S53

ELECTRO-MEDICAL APPARATUS^''-.,.
Cavendish Electrical Co. Ltd.. . . . xxi

Co.x, H. W. & Co. Ltd XX

Dean, Alfred E. . . . . . . 923

Medical Snp)^ly Association . . . . 914

Mottershcad 8z Co. . . . . . . 934

Newton & Wright Ltd. . . . . xv

Sanitas Electrical Co. Ltd. . . . . xix

Siemens Brothers & Co. Ltd. , . xvii

ENGRAVERS—

Bale, Sons & Dauiels«on Ltd. . . . . Sos

Swain, Jc»hn & Son Ltd. . . . . S05

FOODS, MILKS, Etc.

Archeva Rusks . . . . . . . . 943

Brand Co. Ltd., Beef Essence, etc. lii
Bmssou Teune (Tlierapeutic Foods
Co.) .*. . . . . . . . . exxi

Cadbury’s Cocoa . . . , . . 949

Callard & Co., Diabetic Foods . . 940

Casein I,td. . . . . . . . . 048

Colman, J. & J. Ltd. IMustard, etc... 94S
Fry, J. S*. & Sems Ltd., Cocoa

Front End Paper
Horlick’s Malted Milk.. ., Ixxxii, 79s

Maltine Manufacturing Co. Ltd. . . ii

Medic'll Enterprise Sociely I,td. .. xxxv

Ovaltinc . . . . . . . . . . exxi

“ Pitman ” Health Food Co. , . , . 950

Valentine’s Meat-Juice Co. . . . .Ixxxv

FUNERALS, CREMATION, Etc.—
Bond, W. S. . . . . . . . . Soa

London Necropoiis Co. . . , . 91S

HEALTH RESORTS—

{see “ Hydros., Baths, Spas,” etc.)

cxxvm

INDEX TO ADVERTISERS

PAGE

HOMES FOR INVALIDS—

(see also “ Incbrialcs, Homes for.”)
Ablaev Oreci:, Jedburgh .. 866

Baniiirdo's (Dr.) Homes .. . . Ixxx

Beeches, Rcigate Hill, Surrey. . . . 857

Bellevue Sanatorium, Krcuzlingen. . . 869

Bisliopsbourne, East Cliff, Broadstairs
(for Children) . . . . . . . . 865

Eouniemouth Homes for Paying
Patients . . . . . . . . 865

Bristol, IMrs. Gotcli (Patients) . . 861

I^nmton House, Lancaster (Feeble
IMinded Children) . . . . . , 906

Buekeridge Lodge, Teignnionth . . 666

Church Stretton Nursing Home . . S61

Collhurst House Scliool' (for Epileptic

Boys) S57

ConvalePcent Home for E’omen and
Children, New Brighton . . . . 864

David Lewis Colony, Warford (Epi-
leptic) 85 7

r.abiirmtms, Hcronsgatc . . . . 863

Lansifown Grove House, Bath . . 862

Leamington Spa Nursing Home , . 866

Lj'nwood, Housdaole . . , . , , S64

Manna Mead, Blackheath . . . . S63

IMount Ephraim Nursing Home, Tim-
biidgc Wells . . .7 , . . . 866

New Lodge, Billericay (Epilepsy and
IMental) . . . . . . . . S57

Normaiisfield, Hampton Wick (Men-
ially Deiicient) . . . . . . 861

Paris Medical Establishment , . . . S60

Prebend House, Southwell (Neuras-
thenia) . . . . . . . . 861

Op«iCnsberry Lodge, Edinburgh (Ladies) 860
,,,-^esident Patients, Association of

Medical Men receiving . . . . 866

Kosevale Home.®, for Paying Patients,
Erdington . . . . . . . . S62

Z?.oyal Albert Institution, Lancaster
(Feeble blinded Children) .. .. 906

Sanatorium St. Blasien, Black Forest
(Lung Disease) . . . . . .Ixxxii

South Beacon, Hadlow Down (Mental) 862
St. Andrew's Hospital, Dollis Hill, N.W. 857
St. Leonards-on-Sea Niusing Home.. 865
St. Luke's Home, Swanmore (Epileptic) 85 7
St. Thomas's Home, London . . . . 864

St. Ursula, Westditt'-on-Sea . . . . 866

Stoke Park Colony, Stapleton, Bristol
(Mentally Defective Children) .. 906

Val-Hont, Territet (Dictetical) . . 869

HOSPITALS AND MEDICAL
SCHOOLS—

Charing Cross Hospital Medical School S49
Hospital for Sick Children, W.C, . . 85 3

AEddlesex Hospital Medical School . . 842

Plaistow Hospital, E. . . . . . . S48

Richmond, Vliitworth, and Hardwicke
Hospitals, Dublin . . , . . . S50

Rotunda Lying-in Hospital, Dublin . , liv
Royal College of Surgeons, Edinburgh 651
Royal Eye Hospital, S.E. . . . . S50

Roval Infinnarv, Edinburgh . . . . S46

St. Andrew’s Hospital. DoUis HHl, N.W. S57

St. Andrews University, N.B. . • S51

St. Mary’s Hospital Medical School . , 843

University of Aberdeen .. .. 851

Bristol . . . . . , . . S44

Durham . . . . . . . . S45

Edinburgh . . . . . . 847

Liverpool S49

Manchester . . . . . . 849

— College, Dundee . . . . . . 85 1

of South Whales and Monmouth-

, shire, Cardiff . . . . . . S4S

PAGE

HOTELS AND BOARDING
ESTABLISHMENTS—

Cairo, Continental Plotel . . . . lx

— Mena Blouse . . . . . . lx

Davos-Platz, Grand Hotel and Belve-
dere . . . . . . . . . . 86S

Droitwich, Ayrshire House Private
Boarding Establishment . . . . S82

— Worcestershire Brine Baths Hotel S76

Exmouth, Imperial Hotel . . . . 873

Franzensbad, Hotel Kopp Konigsvilla 879
Harrogate, Prospect Hotel . . . . 879

Helouan, Grand Hotel ' . . Ix, Ixi

— Hotel des Bains . . . . lx, Ixi

Ilfracombe, Cliffe Hydro Hotel . . 878

London, Hotel Windsor , . . . Ivi

— Kingsley Hotel . . . . . . hdi

— Tha<^eray Hotel . . . . . . Ivii

Madeira, Reid’s Hotels . . . . lx

ilalvem, British Camp Hotel . . . . S80

— ^lalvem House Hotel . . . . 883

^tlargate, Endcliffc Hotel . . . . S79

Peebles, Peebles Hotel-Hydro . . 871

Soutliport, Prince of Wales Hotel . . 88 2

Strathpeffer Spa, Ben Wyvis Hotel . . 8 74

Tunbridge Wells, Grand Hotel . . S70,

— Spa Hotel . . , . . . . . 877

Woodhall Spa, Victoria Hotel .. 88 1

HYDRO-THERAPEUTIC ESTAB-
LISHMENTS, BATHS, SPAS.
HEALTH RESORTS—

Bath, Hot Springs . . . . . . 877

— Lansdown Grove House . . . . 862

Bristol, The Hydro . . . . . . 8 77

Buxton Spa 875

Cairo, Egypt . . lx

Caterham Sanitarium and vSurrey Hills

Hydro . . 882

Droitwich Brine Baths Spa . . . . 876

Edinburgh, Baths 8 77

Helouan Baths lx, Ixi

Ilfracombe, Cliff Hydro Hotel . . 87S

Ilkley, Craiglands Hydro . . . . 8 78

Krcuzlingen, Bellevue Sanatorium . . 869

Malvern "as a Health Resort . . .. 88 1

— SXalveni Hydropathic Establish-

ment . , . . . . . . SSo

Matlock, Rockside Hydro . . . . S72

— Smcdley's Hydro , . . . . . 8 73

Paris, Medical Establishment . . . . 860

Peebles Hotel Hydro 87 1

Ripon Spa . . . . , . . . S70

Southport, Kenw'orthy’s Plydro . . SS2

— Smedley Hydro ’ . . * . . . . S82

Territet, Val Mont . . . . . . S6g

Trefriw Chalybeate Wells . . . . 87S

Tunbridge Wells Spa . . . . . . 87 7

Woodhall Spa 881

j ILLUSTRATIONS—

I Bale, Sons 8: Danielsson Ltd. . . . . 805

j Swain, John & .Son Ltd. . . . . 805

I INEBRIATES (HOMES FOR)—

Abbotswood House, Cinderford .. 588

Ashford, near Staines .. .. .. 88 6

Bnntinglord House Retreat, Herts... SS7
Capcl Lodge Retreat, near Folkestone 8S9
Comgreaves Lodge, Erdington . . SSS

Cranbourne Hall, Jersey . . . . 903

Dalrvmple House,’ Rickmansworlh , . SS7
Ellison Lodge, Heme Hill . . . . SSS

Farn ham House and Mar.vvillc, Dublin 904

1 Gh}llwoods, near Cockerinoulh ,. 886

INDEX TO ADVERTISERS

CXXlX

PAGE I

Inebriates (Homes FOR)~--co»tinueiL j

Grove Retreat. Fallowfield . . . . 88S

Hamond Eodge, Terrington St. Clement SS8
Invemitli Lodge, Colinsburgh, bife . . SS5
Melbourne House, Leicester . , . . 889

Northlands Retreat, Wandsworth

Common . . . . . . . . 8SS

Norwood Sanatorium, Beckenham Park 886
Sidlow Manor, Reigate . . . . 88S

Spdthome S. Marv and S. Bridget’s,

Bedfont 888

Temple Lodge, Torquay . . . . 888 j

PAGE

Nurses* institutions—

Mental Nurses’ Co-operation, London S59
Retreat, York (Mentkl Nurses) . . 898

Royal Devon and Exeter Hospital
(Private Nursing Branch), Exeter. . S60

St. Luke’s Hosnital (Trained Nurses) 860
Temperance :Male Nurses’ Co-operation liv
Victoria Institute. Bournemouth . . 865

NURSING HOMES—

(see ‘‘ Homes for Invalids.”)

LIBRARY (MEDICAL AND
SCIENTIFIC)—

Lewis, H. K. . . . . . . . . 816

MASSAGE. EXERCISES. Etc.

Cottle, Perdval C., Bath . . . . 850

Edinburgh Institution . . . . 877

Harwood, Mrs., Chorlton-cum-Hardj',
Manchester .. .. .. 85S

London School of Massage, etc. . . 856

Swedish Training School for Massage
and Remedial Exercises . . . . Iviii

MEDICAL AGENTS AND SOCIETIES
Association of Medical Men receiving
Resident Patients . . . . , . 866

London & Counties Medical Protection

Sodety Ltd 855

Manchester Medical Agency Ltd. . . 854

Medical Defence Union Ltd. . . . . 854

MICROSCOPES AND APPARATUS
FOR PHOTOMICROGRAPHY
AND BACTERIOLOGY—

Baker, C. . . . . . . . . xviii

Bausch & X^mb Optical Co xvi

Davidson, F. & Co., Micro-Telescope xviii
Kodak Ltd. (Wratten Division), Photo-
micrography . . . . . . . . xiv

Leitz, E . . . . . . xiv

PRINTERS—

Wright, John & Sons Ltd, . . cxxxiv

PUBLISHERS— the Alphabetical
List of Books and Periodicals,
with Authors’ names, page cxxxi)

Ixii,

sVs,

tS20,

Adlard & Son . .

Ash, C., Sons & Co. Ltd.

Bailliere, TindaU & Cox 807, S32,
Bale, J., Sons & Danielsson Ltd.
Benninghoven (Dr.)

Butterwortli & Co. Ltd.

Cambridge Literar\' Agenev
CasseU & Co., Ltd. . .

Churchill, J. & A.

Doctors* Accountancy Bureau
Heinemann, Wm.

Henderson & Spalding ,

Hilton & Co. . .

Jones, Percival, Ltd. . .

Lewis, H. K

Livingstone, E. & S. . .

Macmillan & Co. Ltd.. ,

Sdentific Press Ltd.

Thacker, W. & Co. (Thacker, Spink &

Co.)

Wright, John & Sons Ltd., cxxxiv,
787, 792, 804 811, 814, 825-829,
833» 858, S89, 905, 936, 942

816,

“34
S09
84 X
S05
Sod
Ixiii
S14
810

821
806

8x5

S40

812

S38

817

822
S23

835

824

RAILWAY ROUTES—

G.N.R. to Ripon Spa.. .. S70

MINERAL WATERS. NON-
ALCOHOLIC DRINKS, Etc.—
Burrow, W. & J., Malvern Waters . . 942

Eviau-Cachat Water . . . . . . liii ■

Hunyadi Janos Natural Aperient Water iii j
Spencer, Layton & Co., ” R.T.B.” . . 950 1

Vittel Grande Source Waters . . 942

MISCELLANEOUS—

Adjustable Grate Co., Grates . .xxxiii
Bennett, J. O., ” Pauma ” Book Rest 928
Boulton & Paul Ltd., Wind Shelters, . 934

Fredericks, Sanatoria Buildings . . 91 S

Hobson, J. T. & Co., Revolving Shelters 935
Patent Pulp Mfg. Co. Ltd., Pulp Ware Iv
Peile-Seyfang Foot-Rest for Children Iviii
Sage, Fredk. & Co. Ltd., Brass Plates 924
Staples & Co., Mattress . . , .xxxiii

NURSES’ INSTITUTIONS—
Co-operation of Temperance Male and
Female Nurses, London . . . . 85S

Lansdown Grove House, Bath . . 862

Leamington Spa Nursing Association 866
London Temperance TSIale and Female
Nurses’ Co-operation, London . . S59

Male Nurses' Association, London . . 8'59

SANATORIA—

Fritton Beedies, Norfolk . . . . SS4

Home Sanatorium, Bournemouth . . S84

:Mendip Hills Sanatorium . . . . 88 3

j Moorcote Sanatorium, Eversley , , 861

' Rostrevor Sanatorium, Warrenpoinl. . S84

Rudgwick Sanatorium, Sussex . . 8 84

Ruebury Sanatorium, Osmotherley . . 883

Sanatorium St. Blasien, Black Forest Ixxxii
Vale of Clwj’d Sanatorium, Ruthin . . S83

Weiisleydale Sanatorium, A^'sgarlh.. 88 4

SANATORIA BUILDINGS,
SHELTERS, Etc.—

Boulton & Paul Ltd. . . . . . . 934

Fredericks . . . . . . . . 91S

Hobson, J. T. & Co 935

SCHOOLS—

(see “ Educational Institutions.”)
SPAS—

(see Hs'dros,” etc.)

STAMMERING—
(sffl ” Tutors.”)

c:-:rc:

INDEX TO ADVERTISERS.

PAGE

STEAMSHIP LINES—

Bibby 3iail Steamers . . . . 854

l*aciilc vSleam jNavisjation Co. . . . . 867

Royal IMail Steam Packet Co. . . . . 867

SURGEONS’ APPOINTMENTS—

Bibby Line Mail Steamers . . . . 854

SURGICAL INSTRUMENTS AND
APPLIANCES, BANDAGES,
TRUSSES, Etc,—

Alexander & Fowler, Slerili2er . . xxvi
Allen & Haiiburys Ltd., Instruments

908, 909

Allen, J. & Sons, Turkish Bath .. 932

Barth, Geo. & Co., Inhalers , . . . xxii

Bennett, J. O., “ Pauma *’ Book Rest 928
Browne & Saycr, Instruments, etc- . . 935

Clarke, John & Co. (Successors) Ltd.,
Bandages and Catheters . - . . 934

Coles, W. & Co., Trusses . . 788-791

Critchley, J. & Sons, Splints, etc. . . 930

. Dental Manufacturing Co. Ltd., Dental
Instruments . . . . . . . . 928

Domen Belts Co, Ltd. .. .. Ixv

Down Bros. Ltd., Instruments 910-913

Bgarte, Madame, Belts and Corsets , . 924

Freeman, J., Orthopaedic Footwear . . 934

Gardner, J. & Son, Instruments , . 931

Grossmith, W. R., Artificial Eyes and

Limbs 932

Harris, Philip Sc Co. (1913) Ltd., Instru-
ments . . . . xxviii, xxix, xsx, xxxi

Hawksley & Sons, Instruments . . 95 1'

Haywood, J. H. Ltd., Appliances . . 931

Hearson, Chas. & Co. Ltd., Incubators 924
Holbom Surgical Instrument Co. Ltd. 920
Holden Bros., Natureform Footwear. . 933

Holland & Son, Instep Arch Socks . , 933

Hospitals & General Contracts Co. Ltd. 921
Liverpool Lint Co., Surgical Dressings 937
Mayer & Mdtzer, Instruments . . 923

Mescal Enterprise Society Ltd. . . xxxv
Medical Supply Association, Instru-
ments 914, 915

Millikin & Lawley, Instruments . . 935
Oppenheimer, Son & Co. Ltd., Sprays xxxii
Patent Pulp Mfg. Co. Ltd., Pulp Ware Iv
Peile-Seyfang Foot-Rest for Children Iviii
Reynolds & Branson Ltd., Ledger

Cards xxiii

Rice, Wm. S., Ltd., Trusses . . . . 930

Robinson & Sons Ltd., Dressings . . 926

Rogers, Frank A., Sprays . . . . xxv

Skeffington’s Invalid Lifters , . . . 907

Staples & Co., Mattress , . . .xxxiii

Stevens, T. C., Turkish Bath .. 932

Sumner, 'R- & Co. Ltd., Instruments,

Front End Paper and iv to xiii

PAGE

Surgical Instruments, 'StTQ,— continued.
Surgical Mfg. Co., Instruments 916, 917

Synics & Co. Ltd., Sprays , . . . 936

Teske, C. A., Ltd., Instniments . . xxvii
Thacki-ay, Chas. F., Instruments gi8, 919
Weiss, John 8: Son Ltd., Instruments 932

Western Dental Mfg. Co. Ltd 929

Wood & Blake, Instruments . . . , 924

Young, Archd., & Son, Sterilizer . . 025

THERMOMETERS—

Zeal, G. H. . . . . . . . . xxxii

TRANSLATIONS (French and Geiman
Medical Literature, etc.) —

Newbold, Miss A . . S12

TUTORS (sec also “ Educational
Institutions *’) —

Bdinke, Mrs. Emil (Stammering) . . 856

Cottle, Perdval C., Medical Gymnasium 8^0
Harwood, Mrs. (Massage, etc.) . . 858

Home Students College Ltd 852

Kent Agricultural School . . . . 852

London School of Massage, etc. . . 856

Medical Correspondence College . . 852

Miall, Prof. J. H. (Stammering) . . 856

Peile-Seyfang School of Health Exer-
cises . . Iviii

SchneHe, A. C. (Stammering) . . . . 856

Sdiool for the Blind, Leatherhead . . Iv

School for the Deaf, Northampton . . 856

Swedish Training School for Massage
and Remedial Exercises . . . . Iviii

Weymouth, E. S., M.A 853

TYPEWRITING—

Newbold, Miss A 812

VACCINE LYMPH—

Rebman's Calf Lymph . . . . 815

Roberts & Co.. Chaumier’s Calf Lymph 947
Sumner, R. & Co. Ltd xiii

X-RAY APPARATUS—

Cavendish Electrical Co. Ltd. . .

Cox, H. W. & Co. Ltd

Dean, Alfred E.

Kodak Ltd. (Wratten Division),

Plates

Medical Supply Association ..
Motteishead & Co.

Newton & Wright Ltd.

Sanitas Electrical Co. Ltd. , ,
Siemens Brothers & Co. Ltd.

AT-ray

xxi

922

xiv

914

934

Xix

xvii

LIST OF BOOKS

Advertised in the Present Yoeume.

For a List of the Principal Medical Worlis and Wv Editions published during 1915,

see page 733.

I>AGE 1

Abdominal Hernia (Bennett) Longmans 809 1
Abdominal Surgery (Curtis) Med. Pub. Co. 810 '
Abdominal Viscera, IMaJignant Tumour 1
Diagnosis of (SenanDT) Heinemami Si 5
Account Books, Medical . . . . Letvis 8r7 i

Account Books, Medical . . Menzies 806 1
Aequanimitas (Osler) .. .. Lewis Si^ j

Age and Old Age (Walsh) Everett Six

AnsEsthesia, Eocal (Schlesinger)

Heinemami 815
Anaesthetics (Buxton) . . . . Lewis 816

Anaesthetics (Hewti') . . Macmillan 823
Anatomical Diagrams . . . . Bale 805

Anatomical Models . . Benninghoven 806
Anatomy, Applied (SKiRiTjsrG) Livingstone 822
Anatomy, Catechism Series Livingstone 822
Anatomy, Surgical (Whittaker)

Livingstone 822

Anatomy, Surgical Applied

(Treves & Keith).. Cassell 819

Appendicitis (Eccles) . . . . Bale S07

Arteries and Angina Pectoris (Allbutt)

Macmillan 823

Arthritis Deformans (Ei-e\vellyn) Wright S29

Bacteriology and Haematology (Esiery)

Lewis 816

Bacteriologj", Medical .. Livingstone 822

Bandaging and Surgical Dressing (Pyb’s —

Clayton-Greene) . . Wright 936

Blood Cells, Biology of (Gruner) Wright 825
Brain and its Membranes, Surgery of

(Ballance) . . . . Macmillan SoS

Brain and Spinal Cord, Anatomj’

{WHITT.AKER) .. LivitigstOKC 822

Cancer of the Breast (Handley) Murrav S07 !
Card Index Sx'stem . . . . Bale 8 05 \

Cards, Ledger Reynolds & Branson xxiii j
Case Book, Pocket.. ' .. .. Lewis S17 (

Cataract (SinTii) , . . . Thacker 824 !

Cerebral Decompression (Ballance) |

Macmillan 808

Charts and Clinical Figures . . Bale 805 ■

Charts and Chart Holders . . Wright 861

Chemistrj-, Manual of (Luff & Candy)

Cassell 8ig

Children, Diseases of (Goodhart & Still)

Churchill S20

Children in India (Birch) Thacker S24

Children, Medical Diseases of (IMiller)

Wright 829

Circulation and Respiration (Brunton)

Macmillan 811

Circulation, Therapeutics of (Brunton)

Murray Sir

Clinical INIemoranda for Practitioners

(Brand & Keith) . . Bailliere 813
Clinical Methods (Hutchison & Rainy)

Cassell 819

Colon, Diseaess of the (IMiuhhery) Wright 82S

PAGE

Cookery, Invalid and Convalescent

(Birt) . . . . Wright 942

Cranial Surger\" (Curtis) Med. Pub. Co. 810

Deafness, Giddiness, etc. (Woakes) Lewis 810
Deformities (Tubby) Macmillan Si 3, 823
Dental Anatomy and Physiology

(Hopevvell-Sshth) .’. Churchill 821

Dental Surgery, Anaesthetics in

(Coleman & Hilliard) .. Lewis Si 7
Diagnosis of Main Symptoms, Index of

Differential (French) Wright 835

Diagnosis, IMedical {Ste\'EN 5 ) . . Lewis 817

Dictionary, German-English Medical

(Meyers) . . . . Churchill 82 1

Dispensing Made Easy (Sutherl-And)

Wright 82 9

Dreams (Freud) . . . . Heine maun 815

Doctor’s Daily Register (^-Ienzies) . . 806

Ear, Diseases of the (Milligan &

WiNGRAVE) .. .. Macmillan 823

Electricity, Medical (Jones) . . Lewis 816
Electricity, Medical, Lectures to Nurses

(Harris) Lewis S17

Electro-Therapeutics (Humphris) Arnold S14
Eye, Errors of Accommodation and

Refraction (Clarke) Bailliere Sio
Eye, Handbook (Swanzy & Werner)

Lewis 8 17

Faeces of Cliildren and Adults

(CAiMAnDGE) . . . . Wright 82 5

First Aid to the Injured and Sick

(Warwick & Tunstall) Wright 936
First Aid Wall Diagrams.. Wright 936

Fcjetus, ilalforniations and Diseases

(Birneaum & Blacker) Churchill S20
Fractures, Simple (Bennett) Longmans S09
Fractures and Dislocations (Stimson)

Churchill S30

Fundus Oculi (Johnson) Adlard 834

Gastro-Intestinal Tract (Wegele)

Heinemann 815

Genito-Urinary Organs, Surgical Diseases
and Injuries of (Walker) Cassell

81S, 819

Gout (Lvff) . . , . Cassell Big

Gumniata (Curtis) . . Med. Pub. Co. 810
j Gjmaecological Surgerj’

(Berkeley & Bonney) Cassell 819

G3’n£ecology, Student’s Handbook

(Herman & Maxwell) Cassell 819

Hair and its Diseases (Walsh) Bailliere 81 1
Hare Lip and Cleft Palate (Berry & Lego)

Churchill SoS

Hernia (Eccles) . . . . Bailliere 807

Hj'giene and Public Health (Ghosh) Hilton 812

CXXX13

index to books advertised

PAGE

H3‘iUciic and Public Health

(Parioss & IvEN^wooD) . . Lcwis 8l6
H>'gieiie and Public Health

(VTiitelegge & Newman) Cassell 819
H>*pnotisni (Taplin) . . Littlehiirv 8io

Indigestion, Constipation, I^iver Disorder

(Bigg) . , . . Baillierc S07

Industrial Gas Poisoning (Glaisxer &

lyOGAN) . . . . Livingstone 823

Industrial Dead Poisoning (Oliver) Lewis 817
Infancy and Childhood, Diseases of

(Holt) . . Butterworth Ixii

Infancy and Childhood, Hygiene

(Pordyce) . . . . Livingstone 832

Infancy, Nutritional Disorders of

(Vincent) . . . . Baillierc 809

Infants, ToxEemia in (Vincent) Baillierc Sog
Insanity (Savage & Good all) Cassell 819
Insanity (Suckling) . . Cornish 813
Internal Diseases (Forchheimer)

Butterworth Ixii, Ixiii
Internal Secretions (Sajous) BnUenoorth Ixii
Ionic Medication (Jones) . . . . Lewis 817

Joints and Spine, Diseases

(Marsh & Watson) Cassell 819

Kidney, Movable (Suckling) Cornish 813
Knee Joint, Injuries and Diseases

’(Bennett) . . . . Nisbet 809

Dabour, Difficult (Herman) Cassell 819
landmarks and Surface Markings of the

Human Body (Rawling) . . Lewis 817
I^edger, Medical — Doctors' Accountancy

Bureau 806

Dedger, Medical Lewis 817

Dife Assurance, INIedical Pxaminaiion for

(Hall) .. .. Wright 804

I/iver Abscesses (Curtis) Med, Pub. Co. 810
Diver, Gall-Bladder, and Bile-Ducts

(Rolleston) .. Macmillan 823
Dungs and Pleurm (Powell & Hartley)

Lewis 817

Malingering (McKendrick) Livingstone 822
Massage in Fractures, etc. (Bennett)

Longmans 809

Massage and Electricity (Dowse) Wright 858
Massage Primer (Dowse) Wright 858

Mastoid Abscesses (Curtis) . . Lewis 810
Materia Medica (Bruce & Billing)

Cassell S19

Materia Medica (Ghosh) . . Hilton 812

Materia Medica Notes (Whitla)

Livingstone 822

Materia Medica, Pharmacy, Pharmacology,
and Therapeutics (White)

Churchill 820

Medical Jurisprudence and Toxicology

(Glaister) . . . . Livingstone 822

Medical Jurisprudence for India

(Dyon & Waddell) Thacker 824
Medical Treatment (Yeo) . . Cassell 819
Medicine, Catechism Series Livingstone 822
Medicine, Clinical (Savill) Butterworth ixii
Medicine, Wheeler’s Handbook of (Jack)

Livingstone 822

Medicine, New System of (Allbutt &

Rolleston) . . . . Macfnillan 823

Medicine, Practical (Carter) .. Lewis 817
Medicine, Practice of (Osler) Butterworth

bdi, Ixiii

Medicme, Practice of (Whitia) Bailliere 807
Medicine and Hygiene, Preventive

(Rosenau) . . . . Butterteorih Ixii

PAGE

Medicine and Surgery, Gould & Pyle’s

(Scott) Lewis Si 7

Medicine and Surgery (Sajous) Butterworth

Ixii, Ixiii

'Metabolism (Paton) . . Macmillan 823
Microtomist’s Vade Mccum (Dee)

Churchill 821

Midwiferjb Short Practice of (Jellett)

Churchill 820

Midwiferv’, Synopsis of (Bourne) Wright 826
Midwifery Wall Diagrams (Bonney)

Wright 827

Mind and its Disorders (Stoddart) Lewis 816
Mosquitoes of India (Jasies & Diston)

Thacker 824

Movable or Dropped Kidney (Suckling)

Cornish S12

Natural Therapy and Climatologj*

(Duke & Forbes) Wright 835

Nitrous Oxide and Oxygen for Dental

Purposes, Administration of
(Hewitt) . . . . . . Ash

Nose and Throat (Thomson) Cassell 819

Nose and Throat (Tilley) . . Lewis 816
Nurses, Explanatory Dectures for

(Hawkins-Dempster) Wright 828

Nutrition of Tnfanis (Vincent) Bailliere 809

Obstetric Practice (Berkeley & Bonney)

Churchill 830

Obstetrics (Williams) Butterworth Ixii
Open-Air at Home (Bates) Wright 792
Ophthalmic Operations (Maynard)

Thacker 834

Ophthalmology (Fuchs) Butterworth Ixiii
Ophthalmoscopic Diagnosis (Admi)

Heiiieniann 815

Pathology, Clinical (Panton) Churchill 821
Pathology, Text-book of (Adat^ii &

McCrab) .. .. Macmillan 823

Paralyses (Tubby & Jones) Macmillan 823
Pharmacy, Materia Medica, and Thera-
peutics (Whitla) .. Bailliere 807

Physics, Manual of (Candy) Cassell 819
Physiology, Human (Starling) Churchill 821
Physiology, New (Short).. Wright 826

Plant Alkaloids (Henry) . . Churchill 820
Poisoning (Murrell) .. .. Lewis 817

Prescriber, Pocket (Husband) Livingstone 832
Prescription Books . . Wright 7^7

Psychiatry, Golden Rules of (Shaw)

Wright 903

Psychological Medicme (Craig) Churchill 821
Public Health (Glaister) Livingstone 822
Public Health Chemistry and Bacteriology

(McKail) . . . . Wright 839

Public Health Daw Robertson &

McKendrick) . . Livingstone 822

Quacks, False Remedies and the

Public Health (Walsh) Bailliere 8ri

Rectum and Anus (Mummery) Bailliere 813
Rectum, Anus, and Sigmoid Colon

(FdwaRDs) . . . . Churchill 80S

Remedies, Newer (Fortescue-Brickdale)

Wright 936

Renal Function in TJrinary Surgery

(Walker) .. .. 818

Rhemnatism, Researches on

(POYNTON & Paine) Churchill 820
Rheumatoid Arthritis (Bannatyne)

Wright 829

INDEX TO BOOKS ADVERTISED

CXXXlll

Sewage Disposal in tlie Tropics (Clemesha)

Thacker 824

Sick Nursing and Home Hj’giene

{^I\cr)Ox\L,D) . , Wright 8S9

vSignioidoscope (^Muiimery) Bailliere 813
Skin Diseases (Morris) . . Cassell 819

Skin Diseases (Sibley) . . Arnold 810

Skin Diseases (Walsh) . . Bailliere 81 1

Skin Practice (Walsh) . . Wright 811

Small'pos, Diagnosis of

(Ricketts & Byles) Cassell S19

Small-pox and Vaccination (Hanna)

Wright S27

Small-pox and Vaccination in India

(Tazmes) .. .. Thacker Saif

Spectacles, Prescribing of (Percival)

Wright 827

Soine, Dateral Curvature of, and Flat Foot

(SanTH) . . . . Wright 827

Sprue : Its Diagnosis and Treatment

(Begc) . . . . Wright 828

Stammering, Cleft-Palate Speech (Behnke)S 56
Stomach. Diseases of (Habershon) Cassell

813, 819

Stomach, Diseases of (Dockwood) Z.ewis 817
Surgery, Catechism Series Livingstone 822
Smrgery, Introduction to (Morison)

Wright 828

Surgery, Manual of (Stewart) Churchill 821
Surgery, Slinor (Foote) Butteneorth bcii
Surgery, Operative (Binnie) . . Lewis 817
Surgery, Operative (Treves&Hutchinson)

Cassell 819

Siirgery, Synopsis of (Groves) Wright 8a 6
Surgery, System of (Choyce & Beattie)

Cassell 8ig

Surgery. Urgent (Dejars — Dickie) Wright 826
Surgical Handicraft (Pyb’s — Clayton-

Greene) . . . . Wright 826

Surgical Nursing (Bishop) Wright 838

Surgical Pathologj’ and Morbid Anatomy

(Bowlby & Anbrewes) Churchill 820
Syphilology and Venereal Disease

(Marshall) . , , . Bailliere 814

Syphilis (Hutchinson) .. Cassell 819

Teeth, Extraction of (Gibbs) Livingstone 822

I page

1 Testis, The Imperfectly Descended
I (Eccles) . . . . Bailliere 807

! Throat, Nose, and F^r, Diseases of

(Porter) . . . . Wright S27

' Treatment, Dictionaiy of (Whitla)

Bailliere S07

Treatment, An Index of

(Hutchison & Collier) Wright 825

Treatment, Svstem of (Dathaai & 3 i)NGLiSH)

Churchill 821

, Tropical Diseases (I^Lvnson) Cassell 8tq

Tropical ‘Medicuie (Daniels) Butterworth Kiil
Tropics, Surface Waters in (Clemesha)

Thacker £24

' Tuberculin, Rules for Use of (Bennett)

Wright Si^

Tuberculosis, Eectures to Nurses (Bruce)

Lewis 817

■ Tuberculosis, Treatment of (Laird)
Tuberculosis, Treatment of (Robin)

Churchill S2 1

; Tuberculosis and Lupus (Minchin)
j Bailliere S07

! Tumours (Bland-Sutton) Cassell 819

I Tumours (Hertzler) . . Churchill 82 1

j Urgent Surgery (Lejars— Dickie) Wright 826
I Urinary Surgeia’ (Kido) .. Longmans S13
' Urine in Health and Disease (Hewat)

I Livingstone S22

! Urologj'" (Guiteras) Bulterworth Ixii

, Vaccine Therapy (Allen).. .. Lewis S17
Varicocele (Bennett) . . Longmans 809 '

I Varicose Veins (Bennett) Longmans S09

I Varix (Bennett) . . . . Longmans 809

, Venereal Disease (ALarshall) Wright 814

Waters and Water Supplies (Thresh)

, Churchill 820

i What are We ? (Sutton) . . . . . . 812

. Women, Diseases of (HER3tLAN & IMaxv.’elt )

Cassell 819

i Women, Diseases of (Lewers) .. Leivis Sin
! Wound Treatment (Be.vison) Livingstone 823

PERIODICALS

Bacteriology, Protozoology and General Parasitology,
Bimimghani Medical Review
Bristol Medico-Chinirgical Journal
British Journal of Surgeiy
British Journal of Tuberculosis
Hospital, The

Indian Journal of IMedical Research
Indian Medical Gazette
IiitemaTional Clinics
Lancet, The

Laryngology, Rhinology and Otology, Journal of
Medical Directory

IMedical Director^’ of Australia, New
Medical OfiScer, The
Medical Press and Circular
Practitioner, The . .

Prescriber, The . .

Therapist, The . .

Tropical Medicine and Hygiene, Journal of . .
Tuberculosis Year Book and Sanatoria Annual
Universal Medical Record . .

Wlio’s Who in Science

Zealand, Tasmania, etc.

Review

of .. .. .. 836

Percival Jones S38
Arrowsmith 830
Wright 833
. . Bailliere 841

Scientific Press S35

. . Thacker 824

. . . . Thacker 824

Bulterworth bciii
. . Lancet Offices S31
Adlard & Son 834
Churchill 820
(Loxton’s) Butierworth Ixii

..836
Bailliere 832
. . Practitioner Lid. 830
.. S06

Henderson & Spalding 840
Butierworth Ixiii
Butierworth Ixiii
.. S37
Churchill 821

MEDICAL PUBLISHING
AND PRINTING

are undertaken with a high degree of excellence and the utmost
advantage to authors by

JOHN WRIGHT & SONS LTD.,
Stonebridge, BRISTOL.

No Printing Works in the Kingdom are better equipped or
arranged for this particular class of work.

J. W, & S. also possess unique opportunities for promoting
the sale of such literature amongst the Medical Profession
throughout the World, They will at all times be pleased to
confer with Medical Authors.

Telephone :

No. 115.

Telegrams :

“WRIGHT, PUBLISHERS, BRISTOL,

GLOSSARY

Containing most of the newer terms in this and recent volumes. Additions will be

made annually.

Acapnia. — A state characterized by i
shortage of carbon dioxide in the blood.

It is held by Yandell Henderson and !
others that this is a predominant factor i
in the production of shock. !

Achlorhydria. — Absence of hydrochloric i
acid from the gastric secretions. I

Activator. — A physical or chemical agent
which renders active some other
chemical agent. In medicine the term
is applied almost exclusively to bio- ;
chemical reactions.

Agglutinin. — ^A substance which has the
power of agglutinating such cells as
bacteria or red blood corpuscles. This
power is usually specific, i.e., for each
kind of cell there is a specific agglutinin,
a principle utilized in the Widal test
for typhoid fever. In iso-agglutination
the reaction is wider, the agglutinin
proving more or less active witli all
bacteria belonging to a certain group.

Allergy. — ^The altered reactivity of an
infected animal or person to a second
infection with the same poison.

Amboceptor. — A substance which has
the specific power of binding comple-
ment (q.v.) to the cell (or bacterium)
for which it (the amboceptor) is specific.

Amino-acids. — An organic acid in which
one of the hydrogen atoms of the base
is replaced by NHo.

Anaphylaxis . — A specific susceptibility
which may be manifested by an animal I
or person in response to a second injec-
tion of an organic substance the &st
injection of which was followed by no
toxic results. The animal showing
such acquisition of susceptibility is said
to have become sensitized to that
particular substance (see also Allergy).

Anisocytosis. — An inequality in size of
the red blood corpuscles.

Anoci-association. — ^This word embodies
the prevention of surgical shock as it is
conceived by Criie, who teaches that
shock is the result of expenditure of
nervous energy under the influence of
abnormal stimuli. According to him,
shock is to be prevented by guarding
the brain from such stimuli, by “ block-
ing of nerve trunks in the area of
operation, by preventing aU possible
sources of mental perturbation, etc.
This process of cutting out deleterious
stimuli is “ anoci-association.”

Antiformin. — A solution containing
several alkaline compounds which is
used in the laboratory for the separa-
tion of tubercle bacilli from pathological
products (sputum, urine, etc.) %vhich
contain them.

Antigen. — Extract of bacteria or of
tissue used in that class of serum tests
of which the Wassermann reaction is
the chief, and which is based on the
“ fixation of complement ” process.
The complement (q.v.) is ‘‘ fixed ” by
the union of the antibody or ambo-
ceptor (q.v.), to which it is attached,
with the antigen, i.e., to the extract of
bacteria or tissue for which that ambo-
ceptor is specific.

Autogenous. — As applied to bacterial
vaccines, this adjective denotes those
vaccines which are made from the
patient*s own micro-organisms, as

j opposed to “stock” vaccines, which

j are made from standard cultures.

! Azoturic. — Pertaining to the urinary

I excretion of nitrogen.

Bacteriolytic. — That which dissolves
bacteria.

Oarcinolytic. — That which is destructive
to cancer cells.

Chromaffin. — ^A hybrid word used as an
adjective in connection with cells or
tissues which display an affinity for
chrome salts. Thus the “ chromaffin
system ” is composed of tissues which
possess cells having this property ; its
components are the adrenal and other
ductless glands, and parts of the
sympathetic system.

i Coliform. — An adjective denoting those
micro-organisms which resemble B. coli
communis.

Complement. — A substance present in
blood serum, possibly of ferment nature,
which, when linked by an amboceptor
to a cell, constitutes with that ambo-
ceptor an agent capable of acting upon
the cell. “The cell is the lock, the
amboceptor the key, and the comple-
ment the hand that turns the key.”

Otoscopy. — Determination of the freez-
ing point.

Diadokokinesis. — ^The performance of a
rapid succession of alternating move-
ments, e.g., pronation and supination.

c:cxxv,i

GLOSSARY'

Spinephi-m. — One of the various names
used to denote the active principle of
the suprarenal gland.

Glycyl-Tryptophane. — A compound "of
• ghj-cin and tryptophane radicles, used
for a test in examination of gastric
contents.

Haemodynamic. — Relating to the move-
ments involved in the circulation of
the blood

Hasmolysin. — A substance possessing the
power of dissolving red blood corpuscles
and Lberating their haemoglobin ; if
possessing this property in regard to
the corpuscles of all animals of a certain
group or species it is called an isohaemo-
lysin.

Herpetomonas. — A species of protozoon.

Heterogenous Vaccines are those pre-
pared from organisms derived from
some source other than the patient in
whose treatment they are to be used ;
in such conditions the source is usually
a “ stock ” culture.

Hyperchlorhydria. — Excessive secretion
of hydrochloric acid by the. stomach.

Hyperpiesis. — Abnormally high arterial
tension.

H3^ertonic. — As applied to saline solu-
tions, the adjective denotes those which
contain a higher percentage of salt than
normal human blood serum.

Iontophoresis. — ^The introduction of ions
into the body by the electric current,
for therapeutic purposes.

Leuoopoiesis. — The formation of leuco-
cytes.

Lipoclastio — ^Fat-splitting.

Lipoids are substances such as lecithin
which enter into the formation of
living cells, and which are like fats in
their solubility in organic solvents such
as alcohol and ether. These solvents
can therefore be used for their extrac-
tion from the tissues.

Lipoproteins are combinations of protein
with fatty acids.

Lymphopenia. — Deficiency of lympho-
cytes.

Meiostagmn Reaction. — A test used in the
diagnosis of cancer, based on the esti-
mation of interaction between antigen
and antibody by measurement of the
surface tension of a mixture of the two.

Metreurynter. — An instrument for arti-
ficial distention of the uterine cavity,
e.g., a Champetier de Ribes’ bag.

Microtia. — Congenital smallness of the
ear.

Neurotropic. — That which “ turns to-
wards’* (i.e., has a chemical affinity
for) nervous tissue.

Opotherapy. — The use of extracts of
normal animal tissues as therapeutic
agents.

Opsonic Index. — The ratio between the
amount of “ opsonin ” against a certain
micro-organism contained in the blood
of a person infected wth that organism
as compared with the content of
similar “ opsonin ” in a normal blood.
“ Opsonins ’’ are substances contained
within the blood serum which have
the property of rendering micro-
organisms fit for attack and ingestion
by phagocytes.

Phlebotomus Fever. — ^'A three -day fever
met \vith in the countries around the
Mediterranean, also in India, conveyed
by sand-flies.

Phosphatids are lipoid substances which
are esters of orthophosphoric acid.

Pleocytosis. — Increase of cells (lympho-
cytes) in the cerebrospinal fluid’.

Pleomorphic. — Varying in form (applied
to bacteria).

Poikilocytosis. — Variation in the shape
of the red blood corpuscles.

Polychromatophilia. — Variability in the
staining affinities of the red blood
corpuscles.

Pol3mucleosis.— Polymorphonuclear leuco-
cytosis.

Polypeptide. — Peptides are compounds
formed by the union of two or more
amino-acids ; polypeptides are formed
by the union of ihore than three such
acids.

Polyvalent Sera are those which contain
antibodies active against many strains
of the same micro-organism.

Pyelography. — X-ray photography of
the renal pelvis after injection through
the ureter of some opaque substance
such as collargol.

Sensitization. — (See Anaphylaxis, above).
SpirlUicidal. — That destroys spirilla or
spirochaetes,

Sporogeny. — Reproduction by spores,
and especially sporulation after fertili-
zation.

Thyrotoxicosis. — Poisoning by thyroid
secretion.

Trophoadema. — Persistent oedema of the
lower limbs ; usually applied to
Milroy’s disease, a hereditary condi-
tion characterized by this type of
oedema.

Tr3rpanocidal. — ^That destroys trypano-
somes.

THE MEDICAL ANNUAL

Part I . — 1 he Dictionary of Materia Medica
and Therapeutics.

REVIEW OF THERAPEUTIC PROGRESS. 1913.

FRANK J. CHARTERIS, M,D.,

Lecturer on yfaieria Medico, and TAerapeniuSy Gtascozu University ;

Assistant Physician^ JJ 'estern Infirmary, Gtasgoio.

GENER AL REVIEW.

There is no striking advance to be recorded during the period under
review. A good deal of work has been done by American workers in
the investigation of phaimacopoeial drugs, but the general result has
been unsatisfactor}^ The therapeutic value of camphor, aconite,
and sumbul is questioned. The interest in salvarsan and neosalvarsan
is gradually ceasing, and apparently the profession is beginning to
recover faith in mercury. Lactic acid therapy is out of favour, and
even vaccine therapy is less in evidence than in former years.

DICTIONARY OF REMEDIES.

ACITRIN.

This new preparation is the ethyl ester of phenylcinchoninic acid,
which has been extensively used, under the name of atophan, to
increase the urinary output of uric acid. According to Pietrulla,^
acitrin has a similar action. In normal individuals it causes a rapid
increase in the output of uric acid, which, after continued administra*
tion, gradually falls to normal and then becomes somewhat irregular.
A similar increase is obtained in Gouty individuals, and here the
excretion may remain for several weeks above the normal value.
Accompanying this increased output of uric acid there is improvement
in the joint condition and diminution in pain.

Reference. — '^Deut, med\ Woch\ 1913, 359.

ACONITE.

Rudolf and Cole^ have tested the e fleet of tincture of aconite in
the pulse-rate in health and disease and found that in pharmacopoeial

ACONITE

MEDICAL ANNUAL

closes no slowing action was produced. They conclude that the drug
is in most cases inert. Ail the commercial tinctures failed to give
the characteristic tingling of the tongue when diluted 1-35. Even
a special tincture physiologically assayed and guaranteed to be of
B.P, strengtli gave negative results as regards the pulse-rate, and
when tested three months later was found to be very weak. Crystal-
line aconitine, which ^vas very toxic for guinea-pigs, failed to slow
the pulse when diluted so as to correspond to the B.P. tinctme. It
gave at first the characteristic tingling when diluted 1-35, but after
four months the dilution had to be four times less, which appears to
indicate that aconitine rapidly deteriorates in solutions.

Reference. — ^Amer. Joitv, Med. Sci. 1912, it 788.

ADiaAN*— ( 5 ^^ Digitalis.)

ADRENALIN.

According to Hess and Wiesel,i the intravenous administration of
adrenalin is of value in the nephritis experimentally produced in
rabbits by the intraperitoneal injection of uranium nitrate. Provided
the adrenalin is administered before the onset of the terminal anuria,
it produces a distinct diuretic effect and a diminution in the albuminuria.
Apparently the effect is chiefly a functional one, as the histological
changes are not prevented.

Jona^ suggests the use of adrenalin to constrict the vessels in the
stomach and duodenum, thereby delaying the absorption of Non-
corrosive Poisons. Experiments on rabbits show that this treatment
is useful in cyanide poisoning, as it delays the onset of the toxic sym-
ptoms for some minutes, during which the stomach may be washed
out and antidotes applied. In rabbits which have been given a fatal
dose of cyanide, recovery takes place if 3 c.c, of 1-10,000 are intro-
duced into the stomach within five minutes, and the chemical antidote
given, or the stomach washed out, within the next four minutes, a
little more adrenalin being then given to delay the absorption of any of
the poison which may have escaped. For human beings he calculates
that 3 oz. of 1-10,000 adrenalin solution would be required. In a few
experiments on animals it was found that adrenalin delayed the
absorption of strychnine and aconite, and was of use as a procedure
preliminary to washing out the stomach.

Meyer® finds that adrenalin causes relaxation of the coronary arteries
and increased flow of blood through them.

References. — HVien. kUn. Woch, 1913, 317 ; 'Brit. Med. Jour. 1913, i,
271 ; ^Bevl. klin. Woch. 1913. 920.

ALEUDRIN.

Aleudrin is the carbamic acid ester of a-a-dichlorisopropyl-alcchol.
It has a marked sedative action, relieving pain and, in sufficient dose,
inducing sleep. It is said that it is not followed by any unpleasant
after-efiects. As a rule, the patients wake up feeling refreshed and
bright. Flamm^ has applied it with satisfactory results as a hypnotic

THERAPEUTICS

ARSENITE OF SILVER

in a series of patients suffering from Mental Excitement. He has
never noted any after- disturbance of the gastro-intestinal tract or
deleterious action on the cardiovascular system. It does not seem to
produce headache, seediness, or depression. He finds it of special
value in cases of severe Depression and Anxiety, as it acts \vell even
in fractional doses, and does not produce cumulative effects. To
combat highly excited conditions, he advises the administration of
2 grams. Topp^ states that i to 1*5 gram is required to induce sleep.
As a rule, within twenty to thirty minutes, this dose causes a pleasant
feeling of fatigue, which is rapidly followed by quiet sleep, lasting from
four to seven hours. The drug possesses fairly strong analgesic
properties, and is useful in the treatment of Neuralgia and the
lancinating pains of Locomotor Ataxia, both for relieving pain and
inducing sleep. Small repeated doses of 0-5 gram thrice daily exert
a marked sedative action in Delirium Tremens, and are also useful
when breaking patients of the Drug Habit.

References. — Went. med. Wocli. 1912, 2311 ; klin. Wocli. 1912,

2230.

ALLYL SULPHIDE.

Minchin^ states that allyl sulphide penetrates the tissues rapidly
and exerts a curative action on Localized Tuberculous Lesions,
accessible to this form of treatment. He brings forward a number of
cases where tuberculous joints with discharging sinuses were rapidly
healed by its use.

Reference. — ^Med. Press and Circ. 1913, i, 274.

ANOYARTHYROID SERUM.

Hoffmann discusses the action of serum of sheep from which both
ovaries and thyroid gland have been removed. According to his view,
the result is that in the serum the antagonizing glands secrete larger
quantities than normal. He holds, therefore, that the serum contains,
in the first period after the operation, larger outpourings from the supra-
renal glands and pancreas, and probably also from the hypophysis.
At a later stage, when the compensatory hyperactivity of a gland acting
similarly to those removed is established, the serum probably contains
less of the antagonizing glands. He thinks, therefore, that it should
be gathered soon after the operation. The serum has this advantage
over adrenalin, that it represents the secretion of h^^pertrophied supra-
renal glands, whereas adrenalin is an extract. Anovarthyroid serum
has been used with success in a case of Osteomalacia, in nine injections
of 10 c.c. at intervals of three to six days. Hoffmann considers it
possible that it might also prove useful in Rickets, in the Psychoses
of Puberty, and in Hay Fever.

Reference. — Munch med. Woch. 1913, 693.

ARSENITE OP SILVER.

Rind^ publishes a preliminaiy note on the use of this inorganic
preparation, which he thinks is likely to prove of therapeutic value.

ARSENITE OF SILVER

MEDICAL ANNUAL

The salt is soluble in solution of rhodan and thiosulphates, forming
labile double salts which are not affected by alkalies or inorganic acids.
The salt cannot be injected, as it produces great pain and local reaction,
but by the mouth it is relatively unirritating, and can be given in
considerable quantities for long periods without toxic manifestations.
Though hitherto he has not detected any specific action on any disease,
Rind states that it seems to stimulate the general vitality and power
of resisting disease. He has seen surprising results in cases of Infectious
Diseases and in Metabolic Disorders.

Reference, — ^Wien. kli%. Woch, 1913, 1028.

ATOPHAN.

Phillips^ states that this dx'ug often produces skin rashes, resembling
those seen following the administration of antipyrin. He records
cases where petechial, urticarial, and scarlatiniform eruptions followed
its use. On ceasing to administer the drug, the rashes disappeared
in a few days, and as a rule recurred in a few days after it was resumed.
Reference. — ^Jonv. Amer, Med. Assoc. 1913, it 1040.

BLOOD, TRANSFUSION OF.

Weber^ states that intravenous injection of small quantities of
defibrinated human blood exerts a favourable influence on the course
of Severe Aneemia. The procedure is simple and apparently without
risk. It is safer than large transfusion. In the past four years he has
given the injections forty-six times in eighteen cases. From healthy
individuals 20 to 30 c.c. of blood are removed under aseptic conditions
into a sterile Erlenmeyer flask and defibrinated for five minutes by
gently stirring with a sterile glass rod. After filtration through four
layers of sterile gauze, the defibrinated blood is put into the ice-chest
for twenty-four hours. This procedure diminishes the reaction, as
the fibrin ferment is probably destroyed. Before injecting the blood,
it is thoroughly shaken up and brought approximately to blood-heat
by immersion of the flask in hot water. Five c.c. are then injected
slowly into the cubital vein. In forty out of his forty-six injections
no reaction developed, but in the other four cases there was slight
disturbance, usually ■with slight fever, redness of the face, and occasion-
ally shiverings or rigors. The histories of the cases show that in most
the injection of the small quantity of defibrinated human blood
stimulated the bone-marrow and caused improvement of the blood
picture. The chief change is an increase in the haemoglobin value and
in the number of the red corpuscles. In most cases the injection was
repeated at intervals of ten to fourteen days.

'Reference. — ^Munch. med. Woch. 1913, 1307.

BORCHOLIN.

Mehler and Ascher^ have used borcholin, a relatively non-toxic
preparation of cholin, in Tuberculosis. Cholin and neurin exert an
action on the fatty envelope of the tubercle bacillus. With a 25 per
cent solution of neurin the bacteriol^’sis is very rapid, and in vitro can

THERAPEUTICS

CAMPHOR

be demonstrated macroscopically within one minute. With cholin
the process is slower, but apparently more thorough, since not only
are the granules dissolved, but also the albuminous substances.
Injected subcutaneously, cholin preparations produce an action
resembling that of A'-rays on the skin. After a latent period of several
days, an obstinate dermatitis develops; but if it is injected slowly"
into the blood-stream it produces little disturbance. Too rapid injec-
tion, an excessive dose, or a decomposing preparation (smelling of
trimethylamine) produces a well-marked cholin reaction, with redness
of the face, giddiness, palpitation, transient dyspnoea, marked saliva-
tion, and tear-formation. These symptoms pass oh in a couple of
minutes. The authors use a i per cent solution of borcholin in 07 per
cent sodium chloride, which must be carefully injected into the vein,
as infiltration into the subcutaneous tissue is apt to cause trouble. As
a rule the initial dose was i c.c. of the solution (*oi gram borcholin),
but this can be gradually increased every second day till *25 gram is
reached. More than this should not be given as a single dose. The
theoretical foundation of this method of treating tubercle is that in the
body cholin is formed from the borcholin, and dissolves the tubercle
bacilli, thereby destroying them in situ and producing a cure. The
authors have tested this method in a series of fifty cases, mostly
surgical. The treatment produces an increased serous secretion ; the
wounds become covered with healthy granulations, and heal rapidly
without formation of sinxises. At the same time the general condition
improves, the appetite becomes greater, weight increases, and sleep
is sounder. The general improvement also occurs in pulmonary
tuberculosis, and is accompanied by a diminution or disappearance of
bacilli in the sputum. Even after a few injections, with Ziehl’s staining
the bacilli appear as a row of granules. Generally speaking, they
found that the more torpid the tuberculous process, the less the reaction
after an injection. In florid cases of pulmonary tuberculosis the
initial doses must be small and carefully' controlled, as there is no
doubt that in such cases a febrile reaction is produced. The few cases
reported in detail show that, in some, extraordinary improvement
followed the treatment.

Reference. — ^Munch, med. Woch. 1913, 748.

CAFFEINE.

PaR seems to have discovered a new pharmacological action of
caffeine. He finds that in guinea-pigs it promptly relieves the Bronchial
Spasm produced by peptone, /3-imidoazolylethylamine, and muscarine.
This action, he states, is due to a peripheral stimulation of certain
branches of the sympathetic.

Reference, — ^Deut. med. Woch. 1912. 1774.

CAMPHOR.

Heard and Brooks,^ from a chemical investigation of its therapeutic
value, came to the conclusion that the hypodermic injection of camphor
in oil in doses up to 50 gr. is not of any clinical value as a cardiac

CAMPHOR

MEDICAL ANNUAL

stimulant. Though in laboratory experiments it has occasionally the
power of removing artiiicially-produced auricular fibrillation, it has
no aiDparent action on the auricular fibrillation of disease. They
think that the drug is rapidly changed into the inert glycuronic acid
compound.

Leo^ has an interesting paper on watery solutions of camphor. He
finds that saturated Ringer’s solutions take up 1-500 of camphor.
Heat throws it out of solution, so that a heated solution contains less
camphor than a cold one. The activity of a watery solution is much
greater than that of an oily one. It is more rapidly induced, and with
a much smaller quantity of camphor. Investigations - on animals
infected with pneumococci indicate that camphor has a specific
action against the organisms.

References. — '^Amev. Jour. Med. Sci. 1913, i, 238; Went. med. WocJi.
1913. 591 -

CARBENZYME.

Sticker and Rubaschow^ state that carbenzyme is a sterile prepara-
tion. It can be given as a soda or glycerin suspension. Normal
tissue is not attacked, with the exception of fatty tissue, which is
sometimes digested. The digesting action of carbenzyme is chiefly
exerted on disorganized dead tissue and on the contents of cysts. Its
introduction is only followed by a sharp reaction when it is injected
into acutely inflamed structures or into a local lesion where there is
great tension. Under other conditions its use is followed by prac-
tically no reaction. After the injection of carbenzyme, tuberculous
pus becomes more fluid, serous, and darker in colour. Its use is
indicated in Necrosis of tissue. Cold Abscesses, Softening Glands, and
Tuberculous Hygroma. In Glands the contents are rendered more
fluid, but the connective tissue remains.

Reference. — ^BerL klin. Woch. 1912, 2075.

GHLORMETACRESOIi.

When investigating the properties of a series of phenol derivatives,
Laubenheimer discovered that chlomietacresol was an extremely?’
active Antiseptic. To render it freely miscible with water in all
proportions, it is emulsified with sodium ricinoleate, and under the
trade name of " phobrol ” a 50 per cent solution has been put upon
the market. Kondring^ has tested this preparation clinically, and
finds that a i per cent solution in 70 per cent alcohol is a satisfactory
solution for rapidly sterilizing the hands and skin. This solution is
odourless, and leaves the skin soft and supple. It is suitable for long
operations where the hands require to be cleansed from blood occasion-
ally, which can be done by wiping vrith this solution. For short oper-
ations where this is not likely to be required, a solution containing
one part of phobrol in twenty parts of acetone and seventy-nine parts
of 70 per cent alcohol may be used, but if this solution is used during
the operation it will fix the colouring matter of the blood for several
days. The technique for disinfecting the hands consists in washing for

THERAPEUTICS

COTTON -SEED EXTRACT

three minutes in soap and hot water, cleaning nails, drying with sterile
towel, and then carefully and thoroughly rubbing hands and forearms
with the phobrol solution for five minutes.

Reference. — ''■Deut, med. Woch, 1913, 513.

COPPER.

Cummins^ recommends the use of copper preparations in the treat-
ment of Diarrhoea and Choleraic Diseases. He finds copper sulpho-
carbolate the best form. He gives gr. in watery solution every
hour, and claims that the therapeutic results in intestinal disorders are
excellent.

Reference. — ^Pyescvibev, 1913. IMay.

COPPER, COLLOIDAL.

Encouraged by numerous favourable reports in foreign medical
journals on the use of colloidal copper in Cancer cases, Herschell and
Cowen^ have been using it similarly. Though their records are con-
fessedly incomplete, they feel warranted in stating that in the majority
of malignant cases definite effects are seen. It diminishes pain in a
remarkable manner ; in many cases the tumours retrogress ; haemor-
rhage diminishes ; appetite and strength return. The treatment
undoubtedly does good, and appears to be quite harmless. The
injections should be made intramuscularly, at first every four days,
unless any reaction in the tumour takes place, when the interval
should be slightly increased. The contents of one ampoule form a
single dose. If any pain is produced at the site of injection, a hot
compress may be applied, but as a rule the pain is slight and passes
off in a few minutes.

H, Chabanier, Rollin, and E. Chabanier^ ha\=^e studied the effect of
colloidal copper on the blood of a healthy man and two rabbits. In
the man, the subcutaneous injection of 5 c.c. produced a diminution in
the haemoglobin for four days. The total number of leucocytes fell
for the first two days and then were greatly increased, the rise lasting
for two days and then gradually falling to normal. The increase was
cliiefly in the pol}uiuclear cells, the lymphocytosis being smaller.
The eosinophile cells remain unchanged. The immediate effect of the
injection, in rabbits and man, is to diminish both polynuclears and
lymphocytes, but after the thii'd day a distinct rise is obtained ; and
\vhereas the polynuclear count soon falls again, the lymphocytic rise
is more persistent, lasting (in the case of the rabbits) for several days.
The large mononuclears also show a slight but steady increase.

References. — '^Med, Press mid Circ, 1913, i, 3S7 ; ^Pvesse Med. 1913,
102 .

COTTON-SEED EXTRACT.

White^ used lactagol, an extract of cotton seeds from which the
oil has been removed, with great success in the case of a mother nursing
triplets. The Flow of Milk was so great that the infants were entirely
breast-fed for seven months.

Reference. — '^Pract, 1913, ii, 422.

DIGITALIS

MEDICAL ANNUAL

DIGITALIS.

Hatcher^ publishes experiments which seem to justify his- con-
clusion that stroph anthill and digitoxin rapidly disappear from the
blood-stream after intravenous injection. He could, however, find no
evidence of the rapid destruction or fixation of these bodies in the
tissues. Their removal seems to be chiefly a matter of diffusion. He
could fmd no evidence of them being specially stored up in one tissue
more than another.

Eggleston- points out that digitalis is very slowly eliminated from
the tissues, and that even after all clinical signs of its action have
disappeared it may still be present in considerable amounts. He
terms this the period of latent action. By administering a second
course of digitalis to patients who had exhibited toxic manifestations
under a previous course, he is able to show that the return of the toxic
manifestations is produced in the second instance by a much smaller
quantity of the drug. From this he concludes that it is still present
in the tissues in an active form even after all clinical manifestations of
its presence have ceased.

Eggleston and Hatchei’** believe that the nauseant and emetic effect
of digitalis bodies is due to an action on the vomiting centre, and from
their comparative investigations of various galenical and proprietary
preparations of digitalis, they conclude there is no proof of the conten-
tion that digalen, digipuratum, digitalysatum, or the fat-free tincture
of strophanthus are less actively nauseant or emetic in proportion
to their cardiac activity than any of the better known and less
expensive galenical preparations of digitalis and strophanthus,

Frankel and Kirschbaum^ claim to have discovered a method of
removing toxic saponin bodies from digitalis preparations by precipi-
tating them with cholesterin. They state that in this \vay they can
entirely remove digitonin, leaving the active bodies which produce the
digitalis action. This preparation, adigan, is said to be free from toxic
gastro-intestinal effects.

Reference. — ^Jour. Amey. Med, Assoc. 1913, ii, 38O; 1912, ii, 1352 ;

•Hbid. 1913, i, 499 ; Idhi. Woch. 1913, 605.

DIORADIN.

After an experience of fifteen months of dioradin, Stoney^ believes
that it is of considerable value in Surgical Tuberculosis. It is not a
certain cure, but in some cases its use is followed by more rapid
and certain cure than any other method he knows. , Early joint cases
recover more rapidly and surely with dioradin injections ; more
advanced cases, with suppuration, usually heal rapidly if injections
are started before or at the time the abscess is opened. In cases with
septic infection the injections reduce temperature, improve appetite
and weight, diminish discharge, and in some cases effect a cure. They
can be given either subcutaneously or intramuscularly, and produce
no pain, local reaction, or constitutional disturbance.

Reference. — Med. Joitr. 1913, i, 215.

THERAPEUTICS

ERYSTYPTICIN

0IPLOSAL.

Diplosal, salicylo-salicylic acid (OH.C,.H^COO,C(iH^COOH) is formed
by the condensation of two molecules of salicylic acid, forming the
salicylic ester of salicylic acid. It is claimed that it is less toxic than
salicylic acid, but MacLachlan^ found that with a much smaller dosage
it produces the same clinical signs of toxic action as other salicylates.
Hanzlik^ finds that diplosal is about twice as efficient as sodium salicy-
late, but is also twice as toxic, though the salicylic acid content of
sodium salicylate is 85*6 per cent and that of diplosal io6‘2 per cent.

Reference. — ^Joitr, Amer. Med. Assoc. 1913, ii, no ; ^^hid. 1913, 959.

EMMENAGOGUE OILS.

Macht^ has studied the effect of direct application of various volatile
oils populai'ly used as emmenagogues and abortifacients, and finds
that they have no direct stimulating action on the uterine contraction
or toxicity, but inhibit or paralyze the contractions of the surviving
uterus. On the other hand, many of them are active poisons. The oils
tested were oils of rue, savin, pennyroyal, tansy, turpentine, thyme,
and apiol. They have all little if any therapeutic value as
emmenagogues, and should be deleted from the pharmacopoeia.

Reference. — ''■Jouy. Amer. Med. Assoc. 1913, ii, 105.

ERGOT.

• The cock’s-comb test is used as a qualitative estimate of the activity
of ergot preparations, but an analysis by Crawford and Crawford^
shows that only one of the many bodies isolated fi*om ergot readily pro-
duces blueing of the comb. Tyramine (para-hydroxyphenylethylamine)
does not produce it. Isoamylamine hydrochloride was also negative,
and ergotoxin produces only slight blueing. Further, the addition of
tyramine does not intensify the action of ergotoxin. On the other
hand, beta-iminazolylethylamine rapidly produces blueing, with fall of
the blood-pressure. Paraldehyde, which also dilates the vessels in
cocks, produces blueing of the comb. Consequentl3^ it appears likely
that the blueing is not due to arterial spasm, since the vasoconstrictors,
tyramine, iso-amylamine, will not produce it. In view of these facts
it does not seem that the cock’s-comb test can be utilized for accurate
ergot testing.

Reference.*— Aincr. Med. ^Issoc. 1913, ii, 19.

ERYSTYPTICIN.

This combination of secacornin, hydrastinine, and hydrastis extract
is stated to possess valuable properties in checking Uterine Haemor-
rhages* It is usually administered in doses of 20 drops thrice daily.
It is stated to contain in each c.c. *008 gram hydrastinin hydrochloride,
•006 gram hydrastis alkaloids, and o*8 gram liquid extract ergot.
KiebeP reports favourably of its use in Excessive Menstrual Bleeding
and in the treatment of Abortions.

Reference. — Weut. nied. Woch. 1913, 269.

FORIVIALDEHYDE lO MEDICAL ANNUAL

FORMALDEHYDE.

Gross and Barthelemy^ draw attention to the value of formaldehyde
as a Disinfectant. Exposure for forty-eight hours to its vapour
effectually sterilizes rubber gloves, linen thread, dressings, and instru-
ments. Porous articles absorb the vapour and remain sterile even
after the formaldehyde has evaporated. It does not destroy the
tissues or rust metallic instruments. For practical purposes it is
best to use powdered trioxymethylene, which liberates formaldehyde
in the cold. The powder is irritating to the tissues, so that it is necessary
to prevent it coming in contact with the objects to be sterilized. This
can be done conveniently by the use of an autoclave, with shelves or
trays on which the instruments can be placed. A thin layer of the
powder is spread on the bottom of the autoclave and covered with a
layer of gauze. Heating is not necessary, provided that the receptacle
can be kept hermetically sealed for forty-eight hours. For rapid
sterilizing, heat can be used. In this case the powder is not placed
directly on the bottom of the receptacle, but on the lowest shelf, so
that the heat may not displace it. To prevent instruments rusting,
they should be heated for a short time before the powder is introduced,
so that they may be quite dry. Only a low temperature is required
to liberate the fumes, as above 55° C. the formaldehyde vapour begins
to be less active. After the internal temperature has reached this
point the heat should be turned off, and in half an hour sterilization
will be complete. Rubber articles should if possible be sterilized
without heat. Two sets of gloves are recommended. When new they
are used for aseptic operations. After an aseptic operation the glove
is carefully soaped on both sides, washed in boiled water, drained,
turned inside out, and dried. A piece of cotton wool is then put inside
to keep the glove open and ensure that the vapour penetrates. Infected
gloves are soaped, put into a i per cent solution of sodium carbonate
for twenty minutes, washed in boiled water,- or, if seriously contaminated,
boiled for five minutes, dried, and formalinized. Catheters, immedi-
ately after use, are cleaned both inside and outside with soapy water,
and carefully dried before formalinizing. If the calibre is very small,
or the urine was very purulent, it is necessary to boil them for five
minutes. Formaldehyde sterilization is the ideal method of preparing
all kinds of ligatures and surgical dressings, as porous bodies absorb the
vapour and remain impregnated for some time after removal from it.

Burnam's test for free formaldehyde in the urine consists in adding
three drops of 0*5 per cent aqueous solution of phenol-hydrazine
hydrochloride, then three drops of a 5 per cent solution of sodium
nitro-prusside, then excess of saturated watery solution of sodium
hydroxide. Both the hydroxide and urine should be slightly warmer
than blood-heat. One part of formaldehyde in 20,000 gives an intense
blue colour, gradually changing to green, and in a few minutes to
brown. With less than one in 20,000, the first colour is green, then
bro^vn. Burnam claims that the test is delicate down to one part in
150,000, but Smith^ states that a positive reaction cannot be obtained

THERAPEUTICS

GOLD

with greater dilutions than 1-40,000. From an examination of the
formaldehyde content of healthy urine after hexamethylene adminis-
tration, he concludes that the liberation of formaldehyde is not due
to a specific renal , action, but to the presence of acids. It ’may com-
mence in the kidney and be continued in the bladder. Litmus paper
is an unreliable indicator of the acidity of the urine in about 25 per
cent of the cases. {See also Hexamethylenetetramine.)

The power of the urine to liberate formaldehyde is best indicated
by its hydrogen ion content ; the greater the acidity the greater the
power of liberating formaldehj^-de. The requisite amount of acidity
can be secured in almost every case by administering boric acid or acid
phosphate of sodium.

References. — ^Rev. de Chir. 1913, i ; ^Bost. Med. mid Surg. Jour. 1913.

i. 713*

GLANDUOYIN (Extractum Oyariale).

Hirsch’^ believes that the oral administration of ovarian preparations
is responsible for the unreliable results which are obtained. Conse-
quently he has tested the clinical effects of a preparation specially
prepared for him. No details are given of the method of prepara-
tion, but it is said to represent the active principle of ovarian tissue.
Glanduovin is a clear non-albuminous sterile solution which can be
administered subcutaneously without producing any irritation or
after-reaction. It has given good results in cases of Disturbed or
Artificial Menopause. It has no effect upon pain occurring in the
interval between menstruation, but acts well in most cases of
Dysmenorrhoea and Amenorrhcea which are due to lessened functioning
of the ovaries. As a rule he gave one injection (representing 2 grams
of the ovarian tissue) daily till improvement resulted.

Reference, — ^Berl. klin. Woch. 1913, 1819.

GOLD.

Feldt^ has, on the suggestion of Spiess, attempted to make gold
combinations suitable for use in Tuberculosis. It is well known that
cantharidin salts injected subcutaneously produce an inliammatory
reaction in tuberculous diseased areas ; hence he has tested a number
of combinations of cantharidin and gold, which is relatively non-toxic
and yet very potent in inhibiting growth of the tubercle bacilli. The
introduction of ethylenediamine in the ortho -position reduced the
toxicity of cantharidin 680 times without removing its physiological
■properties. He then attempted to confer bactericidal properties on
the cantharidin compound, which is inert in this respect. With gold
he prepared two compounds which proved satisfactory in the curative
treatment of rabbits infected with tubercle. These are cantharidin
ethylenediamine-auricyanide and -aurichloride. In rabbits, where
these drugs can be given intravenously, the dose of -002 gram per
kilo proved non-toxic. In infected tuberculous rabbits such doses
prolonged life for several months, with arrest of the progress in the
various internal organs and increase in weight. Siibcutaneous injections

GOLD

medical annual

pi'oved less satisfactory, as the drug is readily reduced in the tissues
locally and is apt to cause abscess-formation. A possible source of
error will be the fact that in vitro, gold-resistant strains of tubercle are
readily produced, so that probably it will be necessary to use some
form of combined treatment.

Reference. Med. Woch. 1913, 549.

HEXAL.

Hexal (sulphosalicylic acid hexamethyleneteti amine) is stated by
Baumer^ to be a useful antiseptic and sedative for the urinary tract.
He advocates its use in Gonorrhoeal Infections. The drug has a
pleasant acid taste, and should be given in water in increasing doses.
He commences with one tablet thrice daily, which may be increased
to two tablets six times daily if required. It is rapidly excreted, and
there is, according to him, no risk of a cumulative action.

Kowanitz^ states that it is a mild diuretic which rapidly acidifies
alkaline urine, exerts a decided sedative action, and acts as a reliable
antiseptic. He has used it with success in gonori'hoeal and other
forms of Cystitis and Urinary Infections. His average dose was
I tablet (-5 gram) thrice daily.

References. — '^Berl. klin. Woch. I9i3> 1308; ^Vien. klin. Woch. I 9 i 3 > I9*

HEXAMETHYLENETETRAMINE.— also Formaldehyde, Urinary
Antiseptics.)

Talbot and Sisson,^ from a study of the urine of children and infants
taking urotropin, find that it is often excreted unchanged in alkaline
or neutral urine, and is scarcely ever broken down into formaldehyde
unless the urine is acid. When the child is secreting an acid urine
containing formaldehyde, the administration of sufficient alkali to
render the urine alkaline will check its formation. Therefore drugs
which alkalinize the urine should not be given along with urotropin.
They find that urotropin administration is soon followed by the
appearance of formaldehyde in the urine. They have detected it
wnthin the second hour, and it has persisted as long as eighteen
hours after the last dose. While all children are capable of breaking
down urotropin, relatively large doses are often necessary before the
excretion of formaldehyde takes place.

Larogue^ advocates the use of large doses of hexamethylenamine to
prevent Post-operative Tympanites. For two days before the operation
the patient takes 10 gr, dissolved in a glass of water every two hours
between meals while awake. The bowels are cleaned out with a
purge or enema before the operation, and afterwards the patient is
encouraged to drink water containing 120 gr. of urotropin to the
quart. As a rule, it is possible to give the whole quantity in the
twelve or twenty-four hours, and for the next two days the nurse is
told to see that this amount is given daily. The drug is then stopped.
Out of a series of 400 operations of all types, in only four did tympanites
develop. A similar treatment is useful in Catarrhal Jaundice and in
cases of portal infection, e.g.. Colitis, Bile-tract Infection, Duodenitis,

THERAPEUTICS

HYDROGEN PEROXIDE

Pyloric Ulcer. For these conditions about i to 2 dr. should be
administered daily for the first three days ; the drug is then stopped
entirely till the bowels are emptied. An3/ bladder irritation or
hsematuria rapidly subsided on stopping the urotropin.

Leibecke® has demonstrated the excretion of urotropin in the pus of
Middle-Bar Disease and Peritonitis, and in Bronchial pus. He esti-
mated the amount contained in the various forms of pus, and found
that in middle-ear disease the highest concentration was 1-6000 to
1-10,000, w^hich might have some slight antiseptic action. The peri-
toneal and bronchial pus contained smaller quantities of urotropin,
the maximum concentration being 1-15,000 and 1-20,000 respectively.
The largest proportions are obtained two to four hours after adminis-
tration, so that clinically the best plan will be to use doses at intervals
of six or seven hours.

References. — '^Bost, Med. and Surg. Jour. 1913, i, 485 ; ^Ther. Gas.
1913, 470 ; ^Bevl. klin. Woch. 1913, 1698.

HYDRASTININ.

Hydrastinin can be prepared synthetically from piperonaL It appears
to have the same pharmacological properties as the natural product,
causing contraction of the uterus and increase of blood-pressure.
OSergeld and Duhrssen^ find that it equals the action of the more
costly fluid extract of hydrastis, and can be successfully employed
in controlling Uterine Haemorrhages, in relieving the painful forms of
Dysmenorrhoea, and in Excessive Menstruation.

Reference. — ^Berl. klin. Woch. 191^, 64.

HYDROGEN PEROXIDE.

Heinemann^ has investigated the germicidal efficacy of commercial
preparations of hydrogen peroxide. He finds that they are of con-
siderable value, as they cause an enormous reduction in the number
of bacteria, and the decomposition products are harmless. Suspensions
of B. fyphosKs, B. coli, and B. prodigiosiis are very sensitive to its
action in quantities corresponding to 3, 6, and 12 dr. of a 3 per cent
solution of and to 2, 4, and 8 dr. of a 4*5 per cent solution of H,.Oo

per quart of milk. Suspensions of the same bacteria in water are
sensitive to the action of HoO., solutions in quantities corresponding
to 3 and 6 dr. of a 3 per cent solution to the gallon, or to 2 and 4 dr.
of a 4*5 per cent solution to the gallon of water. These results are
accomplished in six hours. Complete destruction is rarely accom-
plished and cannot be depended upon. For drinking water, 3 dr, of a 3
per cent solution and 2 dr. of a 4*5 per cent solution per gallon of water
destroy 99 per cent or more of all bacteria in the course of six hours.
For market milk, if fresh preparations of peroxide are used, 6 dr. of a
3 per cent solution and 4 dr. of a 4*5 per cent solution to the gallon of
milk will destroy 99 per cent of all bacteria, though absolute sterility
is rarely obtained. Unfortunately, commercial preparations are
rarely pure, and their efficacy varies with their age and purity, and

HYDROGEN PEROXIDE 14 MEDICAL ANNUAL

with the air temperature, so that it is not safe to depend upon them
as germicides unless their exact composition at the time of use is
known. Heinemann states that commercial peroxide solutions should
be reserved for emergency occasions, as owing to their cost, uncertain
composition, susceptibility to enzyme and other disturbing factors,
they cannot be relied on, and can never compete with efficient water
filtration and pasteurization of milk.

Reference. — P-Jom', Amer. Med. Assoc. 1913, i, 1O03.

IODINE.

Madden^ has found an alcoholic solution of iodine so satisfactory a
Disinfectant for the skin that he has discarded dressings, though his
patients are largely composed of Eg3J'ptians, whose skins are the dirtiest
that it is possible to imagine. Dalton^ is also very satisfied with
iodine as the sole dressing to clean operation w^ounds. It is simple,
efficacious, and economical, and causes the minimum discomfort to
the patient.

Reference. — ^Bvit. Med. Jour. 1912, ii. 765.

IRON, COLLOIDAL.

Dimond^ points out that colloidal iron occurs in two forms, in which
the particles are differently charged electrically. That form in which
the disperse phase is positive is unsuitable for intravenous or hypo-
dermic injection, as the particles precipitate in contact with the negative
particles of the body colloids. Consequently?' the iron colloid with the
negative disperse phase is the better form to employ, as its hypodermic
injection is painless, and followed by only a trifling discoloration of
the skin. He notes that after the injection the faeces contain more
iron. The therapeutic results are excellent, and after hypodermic
use the number of red corpuscles and the percentage of haemoglobin
increase rapidly. The iron colloids are antiseptic and astringent in
action. Their injection is followed by a slight increase in the relative
percentage of polymorphonuclear white cells, with few lobes in the
nucleus. This effect is temporary only, and ceases as the case improves.
He states that the injections also produce a rise in the opsonic index.
There is a subsequent slight fall, but no definite negative phase. He
thinks that in Erysipelas and Cellulitis the hypodermic administration
of the iron colloids has a marked effect in promoting resolution and
shortening the disease.

Reference. — '^Lancet, 1913. b 13S5.

KAOLIN.

Liermann’s method of Disinfecting the Skin by means of an
alcoholic paste of kaolin is favourably reported on by Kuester and
Geisse^, and unfavourably by Kutscher.^ The technique consists in
washing the hands in hot water, cleansing the nails, and then washing
with 2 to 3 grams of a special kaolin soap (kaolin, potash soap, glycerin,
alcohol). The soap is washed off with sterile water, and the parts
are dried with sterile towels. The hands and forearms are moistened

THERAPEUTICS

LEUCOCYTE EXTRACT

with 5 c.c. of 96 per cent alcohol, and then 2 to 3 grams of the kaolin
alcohol paste are thoroughly rubbed in, so that the papillary lines stand
out white. It is claimed that the kaolin, by its astringent and absorbent
properties, seals up the pores and prevents the deeper-lying organisms
coming to the surface. At the same time it carries in the alcohol,
thus producing a double action. Kutscher, experimenting with this
method, found that there was practically no diminution in the number
of organisms after the disinfection. On the other hand, Kuester and
Giesse claim that in 21 out of 26 experiments the number of germs
that survived was less than 5, and in the other experiments less
than 20 colonies developed in plates inoculated with fluid agar or
saline in which the hands were -washed. No other method of steriliz-
ing the hands gave better results.

References, — yned. Wocli. 1912, 1594 ; klin, Woch. 1913 . 629.

LEPTYNOL.

Leptynol is a 2*3 per cent solution of colloidal palladium hydroxide
in liquid paraffin. It has been used as a means of reducing Adiposity.
It is given as an injection deep into the abdominal fat, as it causes a
good deal of infiltration and ulceration if it is injected into the sub-
cutaneous tissue. The drug is said to possess marked catalytic
properties, and to stimulate the oxidation processes of the body.
Properly injected into the abdominal fat, it appears to be rapidly
enough absorbed to avoid local irritation. Gorn^ has used it in twenty-
live cases in combination with exercise and strict milk diet, and states
that the results were marked. With bi-weekly injections of 50 to 100
mgrams of leptynol he obtained an average loss of 2*7 to 3*4 kilos in the
week. Slight degrees of adiposity react least to the* treatment. He
states that the drug seems to have a stimulating action, and the patients
do not object to the treatment.

Reference. — med, Woch. 1913. 1935.

LEUCOCYTE EXTRACT.

Hiss and Dwyer^ have used this extract in 148 cases of Erysipelas.
Most of the cases were due to surgical operations, and others were
examples of idiopathic erysipelas. Nearly all were severe infections.
The results obtained were evidently very good. In fifty-nine cases
where the treatment was commenced within three days of the first
appearance of the lesion, there were only two deaths, and the average
duration of treatment was 2*3 days. Of eighty-nine cases where the
treatment was instituted after the third day, three died. The injections
seem to be effective even in very young children, as in twelve patients
under one year the fatal cases were only four in number. Excluding
infants under one year of age, the recovery rate works out at 99*27
per cent. The injections usually cause a fall in temperature and a
rapid improvement in the general condition. In practically all the
cases, headache, nausea, and vomiting disappeared within a few hours,
the mind became clear, and the ^patient felt comfortable. In cases

LEUCOCYTE EXTRACT

MEDICAL ANNUAL

treated at an early stage the temperature falls sharply and the disease
ends by crisis. A¥here the treatment is iiistituted later in the disease,
the fall of temperature is less marked, but the general condition is
improved and the disease is cut short. In all cases, treated either early
or late, the burning and aching pain disappears in a few hours. After
the injections the rash may still spread, but alters iii character. Bright
rashes fade, while the diisk3r purplish rash of the asthenic case changes
to a healthier crimson form.

Reference. — ^Med, Bee. 1913. il 466.

LUMINAL,

In the last issue of the Annual it was pointed out that luminal, the
new Hypnotic formed by replacing one of the ethyl groups in veronal
by a phen\d group, is not a very safe drug. Pernet^ saw an
erythematous rash follow its use, and Farnell,^ in two cases after
repeated small doses of 0-3 gram, saw fairly severe and prolonged
toxic symptoms, with persistent drowsiness, ataxia, and absence of the
knee-jerks.

Benedek® has tested luminal carefully in a series of over a hundred
mental cases in regard to its sedative and hypnotic properties. As a
sedative he gives *310 *5 gram subcutaneously several times daily, while
for a hypnotic action he uses 0*74 .gram Itypodermically. Sleep is
produced in less than three-quarters of an hour, and the sedative
action is usually" seen within the first quarter of an hour. The sleep
lasts longer than after h^^oscine, the usual duration being from five
to nine hours. Side actions, in his experience, \vere seldom seen. In
two cases there were cardiac oppression, headache, loss of appetite,
and hebetude, and in a third case the sedative action was unduly
prolonged during the following day.

References. — Med. Jour. 1913. ii, 312; ‘Jour. Amev. Med. Assoc.
1913, ii, 192; klin. Woch. 1912, 1571.

MASSAGE.

Phillips^ calls attention to the value of massage in the treatment of
Malnutrition, Rickets, and various other disorders in children ; Con-
stipation, spastic contractions in Polioencephalitis, or other conditions
where there is destruction of the upper motor neurone. In mal-
nutrition, with loss of appetite, weak fiabby muscles, and distinct pallor,
massage for twenty minutes daily gives excellent results. It is very
useful for babies convalescing from acute illness. In rickets it does
much to prevent deformities. It assists in overcoming constipation,
and is useful in restoring the normal tone to nervous children.

Elmslie ‘2 advises immediate application of a compression bandage
or strapping in Strains, with massage to remove effusion, and movement
of the joint from the first. In Acute Arthritis, gentle massage may aid
the absorption of effusion, but movement of the joint tends to increase
the pathological changes. After the acute inflammatory symptoms
have subsided, movements sufficient to stretch the parts without
causing considerable pain ma}" be started. The aim of the treatment

THEHAPEUTICS 17 MASSAGE

is gradually to increase the range of movement until the normal is
obtained. If no improvement is manifest in a reasonable time, the
joint should be examined under an anaesthetic, which enables us to
break down localized adhesions and to determine whether it is still
possible to secure additional movement. If, under the anaesthetic,
movements are never free, and are only obtained with great difii-
eulty, there is already’ definite fibrous adhesion, and it is usually
better to leave a stiff joint. In the treatment of Fractures the
joints may be moved from the first ; not so the fractured ends of
the bone. As soon as the deformity is removed, the whole limb from
the extremity upwards should be bound up with a firm compression
bandage. The proper use for splints is to prevent a recurrence of
displacement. Massage and gentle movement of the neighbouring
joints may be carried out from the first, provided that the movement
does not tend to bring on displacement again. The massage movement
is easily carried out by the practitioner. It should be light and almost
painless.

Cyriax® states that in the treatment of Backward or Mentally
Deficient Children medical gymnastics are useful as a prelude to
physical education. The treatment must of course be strictly
individualized. Its effect is to develop the latent potentiality of the
brain cells. Increase in muscular power goes hand in hand with
progress of mental development and improvement in the child's sensory
condition. The chief aims of medical gymnastics in cases of mentally
deficient children are to aid in developing the efficiency of the motor,
sensory, and ps^xhic elements of the cerebrospinal system, the mus-
cular system, the sympathetic system, and generally to improve the
constitution. The exercises are passive manipulations, mechanical
shaking and strong vibration applied over the brain and spinal cord,
and local nerve friction. Auditor}^ and visual stimulation is afforded
by telling the child to perform or to imitate movements. Active and
passive, or resisted, movement of joints may be associated with the
other forms of treatment.

Abercrombie^ points out that a muscle can be exercised either by
contracting (concentric action), thus approximating its two ends; or
by strongly resisting a power which is too great for it to overcome
completely (excentric action). Physically, an overstretched muscle is
in the worst possible position to do work. It is much more likely to
do effective 'work if its two ends are not too far separated. This is
often seen in a paretic muscle. In severe wrist-drop the affected
muscles may be quite incapable of raising the hand, but are yet capable
of some work in preventing the dead drop of the wrist when the hand
is passively dorsiflexed. To exercise this power the operator supports
the hand, allowing the part to sink gradually while the patient attempts
to prevent the fall. This method of treatment must not be done so
frequently as to exhaust the muscle : five or ten times at each sitting,
which may be given once or twice daily, is sufficient. The movements
must be given slowly and carefully, with a strength proportionate to

MASSAOE 1 8 MEDICAL ANNUAL

the muscle’s power. Excentric treatment gives better results in lower
than in upper neurone forms of paresis. Of course, the muscle must
still retain some power of contraction, as the method is obviously not
feasible in complete paralysis. Generally speaking, however, it is
possible wherever other methods of movement are. It takes less
time than other methods, and requires no costly apparatus or great
training.

References. — ^Amer, Jour. Med. Set. 1913, L 504 ; “Clifi. Jour. 1913. Aprl.
S ; ’^Med. Press and Circ. 1913, h 523 ; Med. Jour. Feb. 1913, 277.

MERCURY,

Wrighf^ reports a further series of cases due to infection with
micro-organisms which have been successfully treated with deep
intramuscular injections of mercury succinimide. This series represents
all types of disease, but the largest group is formed of B. Coli Infections.
He records numerous cases of this type which responded readily to the
injections.

Clarke- prefers a 1-500 solution of mercuric perchloride in
methylated spirit to iodine as more powerfully antiseptic, non-staining,
and less irritating to the skin, so that it can be freely applied to such
parts as the scrotum, penis, anus, where iodine cannot be used. On
the other hand, the perchloride solution is not irritating, provided that
it is allowed to dry quickly and to evaporate.

References. — ^Med. Pcc. 1913. i, 323; ^Brit. Med. Jour. 1912, ii, 764.

MESBk

Mesbe " is the Indian name for Sidarhomhifolia ctibilguHziana,
which grows in Central America and is used as a remedy for Tuberou-*
losis and Lupus. It owes its introduction as a remedy to a German
planter, who observed good results follow its administration in these
conditions. Mesbe is an extract of the plant. Several observers
record successful results from its administration. The first report is
by Spangenberg.’- Heermann^ saw good results in three cases of
tuberculosis of the throat and ear. Jarosch® tested the new drug in a
scries of twelve cases of phthisis, but was not able to detect any evidence
that it possesses a specific action. He administered it both internally
and locally by means of a spray, and found that there was no increase
of weight, improvement of appetite, or diminution of tubercle bacilli
in the sputum. In two cases at the end of the treatment thei*e was a
severe hccmorrhage. The cuti-reaction did not disappear nor was
there any improvement in the local physical signs or in the A'-ray
photographs. The chief effect seemed to be as an expectorant, the
expectoration being lessened and more easily brought up.

References. — ^ReicJis. med. Anz. 1912. Ko. 18; ^Miinch. mcd. Woch.
1912, iS 9; ^Deut. med. Woch. 1913, 215.

METALS.

Gaylord^ finds that a curative action is exerted on the infiltrating
carcinomatous tumours which grow in the thyroid glands of fish hy
minute traces of metals dissolved in the water in which they swim. The

THERAPEUTICS

NOVIFORM

pi’esence of iodine, arsenic oxide 1-300,000, and perchloride of mercury
1-4,000,000, all produced similar changes in the tumours. Within a
couple of days the improvement commences, and within a week there
is a definite alteration in appearance and histology amounting to a
complete cure. The chief interest of Gaylord’s observations is that
the fish only require traces, whereas mammals require large doses to
cure Carcinoma. He thinks that it is not improbable that even in
mammals the discovery of a suitable combination of metallic salts
may result in a great lessening of the dose.

Reference.— kJin. Woch. 1912, 2017.

NEOSALYARSAN.— (Sea Salvarsan.)

NEUBORNYYAL.

This name is given to the bornyl ester of isovalerylglycoiic acid. It
contains 53 per cent borneol, 34*5 per cent valerianic acid, and 25*7
per cent glycolic acid, and is obtained by heating chloracetic acid
bornyl ester with salts of valerianic acid. After purification by dis-
tillation in vacuo, a colourless, almost odourless and tasteless oily
liquid is obtained, soluble in spirits of wine, ether, benzol, and fatty
acids, but insoluble in water. It is not acted on by the gastric juice,
but in the presence of the alkaline intestinal juices is split up into
borneol, valerianic acid, and glycolic acid. It does not cause unpleasant
eructations, but is best given after meals. Rigler^ has used it with
excellent results in various Nervous Conditions and in Cardiac Neuroses.

Reference. — ^MiincJu med. Wcch. 1913. 249.

NOYIPORM.

This new substitute for iodoform is a compound of bismuth, bromine,
and pyrocatechin. It is stated to be less irritating than iodoform, and
to act efficiently in lessening secretions. Favourable reports by many
surgeons show that it is of value as a dressing for wounds, and recent
reports indicate that it is also of service in gynaecological, ophthalmic,
and nasal conditions. Patek^ found that it acted well in Gynaecological,
Operations, and possesses valuable deodorant and astringent properties.
He employed it either as a powder or as impregnated gauze. It does
not produce eczematous irritation. Freytag^ found the powder or a
2 to 10 per cent ointment useful in Ophthalmic work, especially in
corneal infections, ulcerations, and extraction of foreign bodies. Devoid
of odour, it reduces secretion and promotes epithelialization without
producing irritation. Dinolt® states that gauze impregnated with
noviform is of value in Nasal work, as it dries up secretions and does
not irritate or cause excessive formation of granulation tissue, A
further advantage is that tampons do not adhere, and are thus easily
and painlessly changed.

This new substitute for iodoform seems to possess some valuable
properties. Michaeiis*^ notes that it is a good astringent and deodorant.
It is readily sterilized, and is not affected by light. Of special value is
the fact that it does not form adherent masses in the presence of secre-

NOVIFORrVI

MEDICAL ANNUAL

tioiis. Million^ also praises the drying properties of the drug, which is
of great value in the treatment of Fistulae. He found noviform a
reliable antiseptic in the treatment of Septic Wounds.

References. — mcd, Woch. 1913, 1204; '^Berl. kiln. Woc/i. 1913.
1261; ^Jbid.; ^Jhid, 1912, 1940; ^MiHich. med. Woch. 1912, 1S52.

OPIUM.

Gay^ strongly recommends small doses of opium in the treatment
of Gangrene, and in the premonitorj^ vascular disturbances seen in the
lower extremities of elderly people. In such cases the administration
of small doses of tincture of opium seems to act beneficially, apparently
producing a tonic action and stimulating the circulation, while calming
the nervous system. He commences with two or three drops of the
tincture night and morning, increasing by one or two drops every four
or six days till some improvement is evident, either in relief of pain or
in the appearance of the part. As soon as this effect is obtained, the
dose is kept stationary, and may be maintained for long periods without
harm. Small doses alone are required. Gay has never had to exceed
20 min. in divided doses in the twenty-four hours.

Reference. — ^Thev. Gaz. 1913, 457.

OXALIC ACID.

Fry,i from an analysis of three cases of oxalic acid poisoning, holds
that most of the symptoms are really due to precipitation and removal
of the calcium salts from the various tissues, and that the general effects
are not merely secondary to cardiac depression. To combat them,
lime salts should be given from the commencement, not merely to
neutralize the free acid in the gastro-intestinal tract, but to restore the
salt lost by decalcification. In view of the low absorbability of ordinary
lime preparations, it is well to give the lime combined with fats, so that
calcium soaps may be formed which are more readily taken up.

Reference. — ^Lancet, 19x3, ih 220.

OXYGEN.

Gross^ recommends the insufilation of oxygen into the intestine as
a disinfectant. A duodenal tube is introduced into the duodenum
about 3 cm. past the pylorus, when the stomach is empty. The upper
end of the tube is then connected directly with the regulator of an
ordinary oxygen jar, and the gas allowed to enter slowly. When the
patient complains of distention the flow is stopped temporarily. As
a rule the administration is kept up in this way for an hour to an
hour and a half. For the first week it is given once daily, and for the
next two weeks every second day ; for the fourth week every third
day. When there is evidence of serious anatomical change in the large
intestine, the administration may be made by the rectum. Oxygen
insufflation gives both objective and subjective results. Fermentative
and putrefactive dyspepsia and catarrh are lessened, and pain and
annoying symptoms relieved. Admixture of mucus with the stool is
only slowly removed, and is the last symptom to go. The object of the

THERAPEUTICS

PARACODIN

treatment is to inidbit the gro\\i:h of anaerobic pathogenic bacteria,
and to allow normal intestinal flora to regain the upper hand. This
treatment has given good results in Chronic Fermentative and Putre-
factive Catarrhal Typhlitis and Colitis.

Martinet and HeckeP employ hypodermic injections of oxygen in
Acute Asphyxial Conditions arising chiefly from toxic or infectious
origin — uraemia, diabetes, pulmonary conditions, and tuberculosis.
The injection is practically painless, and is best made into the outer
aspect of the thigh. In chronic cases an injection of 300 to 750 c.c. is
given once or twice a week ; but in acute cases the^^ may be repeated
frequently, and several litres be given daily. The injection should
be made slowly, from five to twenty minutes being devoted to
the introduction of each half-litre. As the result of the treatment
there is considerable rise in the blood-pressure, lowering of the viscosity
of the blood, and a corresponding increase in the hcemoglobin. The
pulse is softened and the respiratory movements become more ample.
Hand in hand w'ith these go an improvement in the general condition,
and a feeling of well-being.

References. — ^Med. Rec. 1912, ii, 9S6 ; ^Presse Med. 1913, 241.

OZONE.

The claim has often been advanced that ozone is of value as a gaseous
disinfectant, and several manufacturers have constructed machines
for developing it, for which the general claim is made that micro-
organisms are killed, odour destroyed, and impure air purified. The
results of two independent investigations^, made in America, are
strongly against the view that ozone is of practical value in any of
these respects. At best it is only a feeble disinfectant, requiring pro-
longed exposure before it produces its action. On the other hand, in
concentrations far below those effective as a disinfectant it is injurious
to the human respiratory tract. It is not powerful as a deodorant.
If concentrated, the intensive odour of ozone masks most smells but
does not destroy them. Thus the ozone ma}- conceal faults in ventila-
tion while not correcting them. As a practical therapeutic agent ozone
is of no value.

Reference. — ^Joitr. Amev. ^led. Assoc. 1913, ii, 1007, 1013.

PARACODIN.

This is a hydrated codeine. Dahl^ finds it a useful drug which acts
in somewhat smaller doses than codeine. It surpasses codeine in
sedative effect, and is a useful drug in cases of Cough. In oral doses
of 0*025 gram, paracodin tartrate removes irritable cough and produces
a sensation of well-being, usually without any after-effect. Occasionally
it acts more powerfully than morphine. In seven cases of Nervous
Sleeplessness it proved a reliable hypnotic. Sometimes unpleasant
side-actions are seen, such as vomiting and, in one case, collapse. His
general verdict is that paracodin is a valuable addition to our thera-
peutic resources, which often acts well, and is not more liable to produce
unpleasant side-effects than other sedatives.

PARACODIN

MEDICAL ANNUAL

Apparently it acts more rapidly and is slightly more narcotic than
codeine, but, like it, produces no constipation or habit formation*
FraenkeP recommends it as a remedy for alleviating cough. He
noticed no unpleasant side-action produced by the drug, and Schwartz'*
has also had a similar experience to record.

Keferences. — ^Deut. med. Woch. 1913, 1304; ^Mmwh. med. Woch. 1913,
522; Hhid.

PELLIDOL.

This substance is the diacetyl derivative of amido-azo-toluol.
Unlike it and scarlet red, pellidol is colourless and is soluble, so that it
can be conveniently made up in ointment form. Bantlin*- found a
2 per cent ointment of great use in the treatment of Intertrigo and
Eczema of infants, and Hoffa^ confirms these statements. He says it
acts well even in dispensary cases, causing no irritation or other
deleterious effect.

Ref-erences. — ^MiUich. med. Woch. 1912, No. 39 ; -Dent. med. Woch. 1913,
1209.

PERMANGANATE OF POTASSIUM.

Barton^ calls attention to the Anaesthetizing effect of potassium
permanganate solutions upon the genito-urinary mucous membranes.
With solutions of 1-2500 to 1-5000 a transitory ansestbesia of the
urethral mucous membrane is produced, which permits the painless
passage of sounds. After irrigation with 1000 c.c. of a 1-5000 solution,
the anaesthesia commenced in two minutes, and lasted about ten
minutes. It takes about five minutes to pass off.

Reference. — \/ our. Amev. JSIed. Assoc. I9i3> h iQd.

PICRIC ACID.

MitchelU reports that a i per cent solution of picric acid in alcohol
has been used by Nifong in 78 cases of Wounds, with very satisfactory
results. The staining of the skin is very intense and tenacious. It is
also necessary to ensure that the edges of the wound are carefully
coapted, as the solution has a marked effect in coagulating albumin,
so that a pocket of coagulated serum may delay the healing of the
wound.

Reference. — ^Ann. Snrg. 1912, ii, 331.

PITUITARY EXTRACT.

EspeuU reports a case of rupture of the uterus after administration of
pituglandol. The patient had borne seven normal children, but the
eighth birth presented difficulties owing to the large size of the infant's
head. This was firmly wedged in the pelvis and the os fully dilated,
when pituglandol was injected, as the cardiac action of the child was
poor and the uterine contractions were feeble and infrequent. The first
h^’podermic injection of i«i c.c. produced no improvement, and a second
injection was given after an hour and a half. This produced violent
uterine action vuthin five minutes, and resulted in rupture of the
uterus. The immediate operation revealed two large lateral rents,

THERAPEUTICS

PITUITARY EXTRACT

which, involved the whole of the cer\’ix and stretched mde into the
parametrium.

Donelan^ is unable to confirm Citelli’s enthusiastic report of the
value of pituitrin preparations in the lessening of bleeding after operations
on the throat and nose. Citelli states that the injection of J to i c.c.
subcutaneously effectually checks haemorrhage in operations on the
turbinates, nasal polypi, tonsils, and in sinus operations, but Donelan,
from his experience in twenty-five similar cases, found that c.c. was
practically useless, and i c.c. gave little better results as regards
bleeding during the operation. In turbinectomies the haemorrhage
was greater with pituitrin than after adrenalin, and during operation
on the mastoid antrum the bleeding seemed to be unaffected b\-
pituitriii, though the after-oozing was less than usual.

Musser® has studied the effect of prolonged administration of pituitary
extract upon the blood-pressure. The preparation used was made from
the whole gland, and was made up in *2 gram tablets containing
*065 gram dried gland, equal to *26 gram of the fresh gland. As a rule,
four tablets daily were required to produce any effect. The adminis-
tration lasted from one week to ten months. In 17 out of 18 cases
a rise in systolic blood-pressure was obtained, the greatest rise being
28 mm. Hg. The diastolic pressure usually increased correspondingly,
but occasionally remained unaffected. The pulse-rate was usually
increased, but in two cases it decreased. Glycosuria was never seen,
but a diuretic effect was noted in six individuals. The intestinal
functions were stimulated. Diarrhoea was noted in seven cases, and
four, previously costive, had daily mo\-enients while taking the drug.
He concludes that the pressor effect was the most constant ; and
it persisted for an appreciable time after stopping the administration.

Houssay and Beruti^ speak very highl}" of the marked action of extracts
of the posterior lobe of the pituitary?- gland upon the intestinal contrac-
tions. They employ a solution containing in i c.c. the active principles
of 20 cgrams of the posterior lobe of the ox. This solution can be
injected subcutaneously without causing pain. To produce evacuation
of the bowels they found that 3 c.c. is the average dose required. The
effect is very prompt. Within two or three minutes intestinal move-
ments are felt, and at any period from six to sixty minutes the bowels
act. It appears that the first effect produced is inhibition of the
intestinal movements, which is soon followed by contractions, increasing
in strength. The action is almost always painless, but the patient
usually becomes pale, and the pnlse-rate increases with the peristalsis.
Occasionally the patient vomits. The evacuation is sometimes
repeated within twenty-four hours, but the action passes off entirely
within forty-eight hours. Clinically the authors have found the drug
very useful in Intestinal Paresis after Operation and in Tympanites.
The chief advantages are the rapidity and certainty with which it acts.

Popielski® holds that there are two bodies in the gland, one of which
is pressor in action and the other depressor. Pituitrin and pituglandol
contain the former, and hypophysin the latter principle. The pressor

PITU8TARY EXTRACT

MEDICAL ANNUAL

substance can be obtained in a relatively pure condition by precipitating
it with phospho tungstic acid, which leaves the pressor substance in the
solution. The filtrate is treated with barium hydrate to remove the
acid, and then this is removed with sulphuric acid. The solution is
then dried and extracted with alcohol. The alcoholic extract is then
precipitated with alcohol sublimate.

Houssay® finds that the combination of adrenalin with pituitrin gives
better results than either drug alone. In suitable combination the
initial vascular depression induced by pituitrin is lessened, and the
subsequent vascular contraction and cardiac stimulation are more
efficient. The most suitable proportion is to mix four or five drops of
adrenalin solution with i c.c. of pituitrin. This mixture may be
injected to overcome shock ; but the two drugs neutralize each other
as regards the intestinal muscles, and the mixture is not suitable for
use as a purgative or to relieve paralytic distention of the bowel. On
the other hand, the combination of the drugs intensifies their astringent
action and makes for a very protracted and efficient vasoconstriction.

References. — '^Miinch. med. Woch. 1913^ "^ 77 A ) ^Jonr. Laryngol. 1913,
353; ^Amey. Jour. Med. Sci. 1913, ih 208; ^Presse Med. 1913, 613; ^Berl.
kUn. Woch. 1913. 1156; ^Wien. klin. Woch. 1913, 489-

SALICYLATE OP SODIUM.— (5^5 also Rheumatism.)

The Council of the American Medical Association on Pharmacy and
Chemistry have been investigating the properties of synthetic and
natural sodium salicydate. The general verdict is that there is no
essential difference between the two. WaddelP showed that there was
no difference in pharmacological action, and Hewlett^ that the clinical
effect is similar, while Plilpert,® after investigating the purity of com-
mercial sodium salicylate, comes to the conclusion that the cheapest
commercial synthetic form is the equal of the higher priced brands of
the synthetic kind or the costly “ natural '' product. Hanzlik*^ finds
that there is no difference in toxicity between the natural and synthetic
salicylate and oil of wintergreen, and that age, sex, diseased condition
or therapeutic response do not modify the toxic dose.

Levin ^ finds that in the goat the method of administering the drug
affects the amount present in the blood-stream, and also the rapidity
with which the drug is excreted. After subcutaneous injection, the
concentration in the blood-stream is less than after intiamuscular
injection or oral administration, and the drug leaves the blood-stream
within ten hours. With intramuscular injection the greatest con-
centration in the blood-stream is obtained, and the drug is not com-
pletely removed for twenty- two hours. Oral administration results in
the prolonged presence of the drug in the blood-stream, in which it can
still be demonstrated for thirty-two hours. On the other hand, the
amount of the drug present at any time is greater than after subcu-
taneous fut much less than after intramuscular injection.

References. — ^Arch. Pit. Med. 1911. 7S4 ; -Jour. Amer. Med. Assoc
1913, ii, 319 ; ^Ibid. 1913, 1137 : ^Ibid. 1913, 957 ; '^Dent. med. Woch. 1912,.
2412.

THERAPEUTICS

SAtVARSAN

SALYARSAN .— also Syphilis.)

In tlie past year it has become evident that the use of salvaisan
alone in Syphilitic conditions is already passing out of favour. In the
practice of many Continental experts it is now the rule to administer
a course of mercury before using salvarsan. It is hoped that this
method will minimize the risk of a marked reaction. There still seems
to be a good deal of doubt as to what produced the angioneurotic
s^miptoms which are sometimes seen to follow intravenous injections
of salvarsan and neosalvarsan. It is, however, becoming more and
more evident that they are vasomotor toxic effect of the drugs and not,
as was formerly supposed, due to the liberation of endotoxins from
local depots of spirochastes in the central nervous system. Last year
we referred to Marschalko’s experiments where haemorrhagic encepha-
litis was produced in healthy rabbits by salvarsan injections.
Indirect confirmation of his results has been obtained by Uhlmann’s
work on the distribution of arsenic in the organs after intravenous
injections. He found that the brain contains only very small amounts
of arsenic. The object of the experiments was to investigate what
experimental evidence there is for Ehrlich’s supposition that salvarsan
is more parasitotropic than organotropic. Uhlmann’s^ work is in
favour of this hypothesis. He found that tissues which normally con-
tained only very small amounts of arsenic under salvarsan treatment,
contained distinctly more if they were the site of syphilitic lesions.
Conversely, the presence of non-spirochaetal disease did not increase the
quantity of arsenic retained by these tissues after salvarsan treatment.

The anaphylactoid, angioneurotic symptoms seem to occur fairly
frequently. Guttmann^ saw them occur in 9 out of 51 cases treated
with salvarsan. In his experience they are much less- frequent -with neo-
salvarsan. They consist in flushing of the face, occasional swelling of
the tongue and lips, and rapid pulse. More surely the respiration is
disturbed. Briickler^ saw’ 9 cases out of 100 show anaphylactoid
S3miptoms. A striking case w’hich is strongly in favour of the vaso-
motor as against the endotoxin theory is recorded by Muller, in wdiich
the symptoms came on, he thinks, as the direct result of impure saline
solution. In the midst of a large series of reactionless injections, he
noted a series of four cases wdth rather severe gastro-intestinal disturb-
ance, in which the same saline solutions were used. In one case the
patient vomited four times on the day of injection. Next day she was
apparently quite well, but on the third day complained of slight giddi-
ness. On the fouith day she suddenly lost consciousness, became very
restless, and show’ed involuntary spasms of the muscles. There was
facial paralysis lasting twenty minutes. Next day she remained un-
conscious, and at different periods showed sudden cyanosis, lasting
half an hour, and then during the next ten hours Cheyne-Stokes
respiration and slow pulse occurred at irregular intervals. On the
next (sixth) day, she suddenly regained consciousness, and all the
alarming symptoms ceased, wdth the exception of the slow pulse.
Miiller thinks that the saline solution probably contained a trace of

SALVARSAN

MEDICAL ANNUAL

some metal, which acted as a catalyser. The sudden and transient
nature of the symptoms can, he thinks, only be explained as clinical
evidence of a profound vasomotor disturbance of the brain. If, as in
his case, the damage is not too profound, the patient may recover;
but in other cases, the vasomotor disturbance leads to the formation of
hyaline thrombi and haemorrhages, constituting the haemorrhagic
encephalitis which has frequently been found in patients who have
died after salvarsan administration.

A typical case of the fatal type is reported by Busac and Merian®
after neosalvarsan. A first injection of o*6 gram was given without
disturbance ; but eight days later a second injection, though producing
no immediate fever or gastrointestinal disturbance for the first two
days, was followed on the third day by headache, slight jaundice, fine
tremor of the hands, and twitching of the body, which slowly, during
the next twenty -four hours, passed into coma, dyspnoea, and con-
vulsions. Death occurred on the fourth day. In addition to haemor-
rhagic encephalitis, there was fatty degeneration of the heart and
parenchymatous nephritis, with proliferation and desquamation of the
glomerular epithelium.

The general verdict is, that neosalvarsan causes less reaction and
gastro-intestinal disturbance than the old drug ; but Simon® states
that he has seen at least two cases of angioneurotic reaction of a very
severe type. Guttmann'^ states that there is no difference in the thera-
peutic action, except that the neosalvarsan seems to be less effective in
modifying the Wassermann reaction.

The non-irritating action of neosah^arsan is taken advantage of by
Castelli,’ who injected it directly into the cerebrospinal fluid of animals.
No toxic action was produced when 0-0112 gram per kilo, body weight
was injected as a i per cent, solution, though the animals were kept
under observation for several weeks.

In place of the usual method of administering dilute neosalvarsan in
saline solution, Ravaut® recommends strong solutions in water. He
dissolves 0*9 gram in 10 cx, of water, and states that he has used this
solution in 420 cases without ill-effects. The solution is given with an
ordinary lo-c.c. “ Record syringe, and the whole amount is injected
into a distended vein in the course of twenty' seconds. He claims
that the use of this small quantit^j- of water eliminates practically both
water and chemical contaminations. Strauss® and Stern^® also recom-
mend a concentrated solution of 5 per cent neosalvarsan in water ; but
Zimmem,^^ as the result of some old experiments carried out in 1911
with salvarsan, is very sceptical about this method, as in his experience
unpleasant results were quite frequent.

Touton,^^ after further experience, confirms his statement that neo-
salvarsan can safely be administered to patients who are unable to lie
up. A preliminary couise of mercury inunctions 01 injections is used
for ten to fourteen days, and the mercurial treatment is kept up during
the period in which the neosalvarsan is used. With a minimum
interval of one week between each, he gives three injections of neo-

THERAPEUTICS

SALVARSAN

salvarsan. The total amount must not exceed 2*25 grams. He gives,
as a rule, o-6 gram, then 0*75 gram, and finally 0-9 gram. For prepar-
ing the injection he uses twice-boiled pure, or nearly chemically pure,
tap-water free from germs, and assists the elimination of the mercury
and arsenic by a course of baths, sweating procedures, and eliminating
saline drinks.

KalF® warmly recommends the use of a neosalvarsan injection as a
valuable diagnostic measure in cases where the Wassermann reaction
is doubtful. Using Stern’s modification, as more delicate than the
original Wassermann technique, he states that in doubtful tertiary
cases the best time to test is on the day following the injection.

Though most authorities now use only watery or saline solutions of
neosalvarsan, Lindenheim^^ strongly advocates the use of intramuscular
injections of joha. He states that the administration is more effective
than intravenous injection, and is practically painless. Yet he, even,
has seen pulmonary embolism result, and Hazen had a similar experi-
ence when using oil}- injections of old salvarsan.

HaerteP ^ reports a case of Chorea in a pregnant woman, which Avas
cured by salvarsan administered intravenously. [The woman had
already had an attack of chorea some years before, which makes it
doubtful whether the second attack was really a case of chorea gravid-
arum as the authors claim. — F. J. C.] Zumbusch^’ used neosalvarsan
without success in a case of Hydrophobia ; but Tonin^s has recorded
the successful treatment of a girl suffering from this disease, by intra-
venous injection of 0*3 gram neosalvarsan. Gerber,^® in an interesting
paper, sums up the curative value of salvarsan treatment in local
Spirochsetosis of the Mouth, CingiYitis, ulcerated gums in Mercurial
Stomatitis, Scurvy, Plant-Yiucent Angina, etc., and advises local
applications of salvarsan and neosalvarsan.

Alwen^® and Loewj^ and Wechselmann*^^ publish independent investi-
gations, which show that a kidney damaged by mercurial treatment is
more susceptible to salvarsan than a healthy kidney. The vascular
response of the kidne}’ vessels to central stimuli (blowing tobacco-
smoke into the nostrils), and peripheral stimulation (injection of epine-
phrin), is slightly affected, but may remain evident, though greatly
diminished, till a late period of intoxication, but the watery excretion
is markedly diminished, and may be completely abolished. The
damaged kidne}^ may secrete non-albuminous urine, so that the absence
of albumin does not necessarily mean that the kidneys are not damaged
by the mercurial treatment. The best indication seems to be the
diminution in the absolute quantity of urine. These investigations
show that there is a certain amount of risk in combining mercurial
and salvarsan treatment, as the kidneys may suffer damage, and
be unable to remove the salvarsan sufficiently rapidly to prevent
poisoning.

Morgenroth and Tugendreich^^ publish some interesting experi-
ments on combined chemotherapy. Ethyl -hydrocuprein is fairly active
as a temporary trypanocide, but sodium salicylate is devoid of trypano-

SALVARSAN

MEDICAL ANNUAL

cidal action, though possibly of slight prophylactic value. .Yet the
combination of inactive amounts of ethyl-hydrocuprein and sodium
salicylate results in a distinct increase in the trypanocidal effect, so
that temporary I'emoval of trypanosomes from the peripheral blood of
infected mice can be achieved. The combination ol these two drugs
with minimal (inefficacious if used alone) quantities of salvaisan gave
certain therapeutic results which led the authors to recommend that
their combination should be tested in human disease, as, if the same
results are obtained in man, the use of the smaller amount of salvarsan
will greatly lessen the risk of arsenic poisoning.

Fleming 23 reports a case of fatal hsemorihagic encephalitis which
caused the death of a young man, 19 years of age, who was suffering
from early secondary syphilis. He was given two injections of o*6 gram
salvarsan at an interval of fourteen days. The first injection caused a
slight reaction, and the second was also followed at first by merely a
slight reaction. In the course of the next two days he fell ill with
epigastric pain and hypersensitiveness to noises. In the course of the
next eight hours he became irrational, then stuporose, and had convul-
sions, dying four days after the injection. The particular interest of
the case consists in the fact that he was one of four men infected on the
same night by the same woman. One other of the four received salvar-
san treatment, which was well borne. This seems to piove conclusively
that the poisoning must be due to an individual susceptibility to salvar-
san, and not to any special potency of the strain of spirochsete. Krolo^^
records a fatal case of salvarsan poisoning in which ecchymosis and
softening of the abdominal muscles developed after repeated intra-
venous injections over the abdomen. Post mortem, a haemorrhagic
necrotic degeneration of the muscular tissue was found.

References. — ^Wien. klin. Woch. 1913, 161, 216, 465, 929, 978 ; ^BevL klin.
Woch, 1913, 581 ; mecl. Woch. 1912, 1587 ; ‘^Miinch. med, Woch. 19131 805 ;

^Ibid. 1912, 2330 ,* ^Jbid. 2328 ; '^Devit. med. Woch. 1912, 1632 ; ^Pyesse Med.
1913, 262 ; ^Milnch. med Woch. 1913, No. 13 ; '^^Devmatol. Woch. 1913. No.
14 : ^^Milnch. mod. Woch. 1913, 1087: klin. Woch. 1913, 484 ; ^^MUnch.

med. Woch. IQ13. 805 ; ^^Berl. klin. Woch. 1912, 217S ; ^^Jour. Amev.
Med. Assoc. 1913 i, 1618 ; '^^Munch. med. Woch. 1913, 184 ; ^ klin. Woe} .

1913. I20g ; Policlin. 1912, July (Presse M6d. 1912, 652) ; ^^Miinch. med'
Woch. 1913, 630 ; '^^Arcl.. f. Exp. Path. u. Pharm. Ixxii ; ^^Berl. klin. Woch.
1913, 1342 ; 1207 ; ^‘■^Attstrai. Med. Gaz. 1913, 568 ; -‘^Mimch. med.

Wocl. 1913, 1712.

SCARLET RED.

Allan^ finds a i per cent ointment of scarlet red useful in Injuries
and Ulceration of the Cornea. It does not cause much discomfort,
but in a few cases he has seen a little irritation follow its use. For
granulating surfaces a stronger ointment (2 to 4 per cent) may be used.

Lyle‘S reports a case of poisoning from the use of 8 per cent scarlet red
ointment. A woman, fifty 3^ears old, after using the ointment for a
large burn, noted, on the sixteenth da^^ headache, dizziness, and
faintness. Next day she vomited, was nauseated, and had severe pains
in the abdomen. The urine contained albumin, but no casts. The

THERAPEUTICS

SILVER, COLLOIDAL

gastric and abdominal symptoms persisted for ten hours. On applying
the ointment a week later the same symptoms developed, though less
severely.

References. — '^Ther. Gas. 1913, i; ^Med. Rec, 1912, ii. 897.

SEA WATER.

Packard^ records a case of apparently hopeless Peritonitis where the
use of marine plasma proved successful after all other measures had
failed. The patient developed extreme tympanites and paralysis of
the bowel after an operation for perforated appendix. As a last resort
100 c.c. of plasma were injected into the gluteal region, and this w^as so
successful that for four days it was repeated twice daily. The patient
ultimately recovered after a localized abscess in the peritoneum had
been opened. Packard states that in two other cases of threatened
peritonitis he has seen good results from the use of sea-water injections.

Reference. — ^Bost. Med. and Siirg. Jour. 1913, i, 544.

SERUM, ANTISTAPHYLOCOCCIC.

Thomas^ has found good results in infections due to Micrococcus
pyogenes aureus with a potent polyvalent serum obtained by treating
a ram with increasing doses of several strains of M. aureus from
different types of human disease. He used it chiefly in a series
of cases of Carbuncles and Furuncles. The results were very good.
No new boils formed, and those present healed rapidly, the therapeutic
effects being more prompt than with vaccine treatment. Of special
interest is the only case of staphylococcic bacteriaemia treated with the
serum. This patient had Acute Osteomyelitis following an osteotomy,
and subsequently the knee and wTist became septic. Vaccines
aggravated the condition,, but mercury succinimide, arsenic, and tonics
led to some improvement. At the end of ten months the serum treat-
ment was instituted, and was immediately followed by great improve-
ment : the wrist healed, sinuses closed up, and the weight increased.
Five injections were given, and in a month the patient was discharged
from hospital.

Reference. — ^Jouy. Amer. Med. Assoc. 1913, i. 1070.

SILVER ARSENITE. (See Arsenite of Silver.)

SILVER, COLLOIDAL.

Netteri uses preparations made both chemically and by electric
methods, but generally prefers the former except for h^^podermic
injections. Speaking of their use in the case of children, he states that
inunction of a 15 per cent ointment is useful in Pneumonia and Broncho-
pneumonia, being usually followed in a few hours by a fall of tempera-
ture and improvement in the general condition. In bronchopneumonia
he often uses subcutaneous injections of electrargol or weak solutions
of collargol, *25 gram to the litre. In severe cases intravenous
concentrated injections of i to 2 per cent can be used, and may some-
times abort pneumonias. They also act well in certain cases of
Infectious Endocarditis, Rheumatism, and Pymmia. They are useful

SILVER, COLLOIDAL

MEDICAL ANNUAL

adjuncts to serum therapy in Diphtheria. Intestinal Infections are
best treated with oral administration of 20 to 40 egrams daily, or by
rectal injections of 0*4 to i gram, which give good results in Dysentery,
Paratyphoid, and Typhoid Fever. One of the most successful applica'
tions consists on the use of a nasal injection of i-ioo in children suffering
from Adenoids.

There seems little risk of producing argyria even after long-continued
use. In one case, where injections were continued uninterruptedly for
two years in an epileptic, a slight argyria was produced.

Reference. — '^Presse MSd. 1913, 21.

SQUILL.

Pic and Bonnamour^ draw attention to the valuable diuretic proper-
ties of squill. In health it has little effect in promoting diuresis, but
increases notably the excretion of urea. In suitable cases of Nephritis
it greatly increases both the amount of urine and the excretion of
nitrogenous bodies. It does not promote the excretion of chlorides to
any marked extent. Hence its chief clinical value as a diuretic is in
those cases of Dropsy where there is a marked reduction in the excretion
of urea. If the chlorides are also diminished, squill should be combined
with theobromin, which increases their removal. When the oedema is
due to cardiac failure, it is good practice to combine squill with digitalis.
The best method of administering squill as a diuretic is in the form of a
powder. They give *15 gram in cachets three or four times daily, and
state that in these quantities it does not damage the renal epithelium
or increase albuminuria.

Reference. — ^Pyesse Med. 1912, 1053,

SUGAR.

Magnus^ has tested sugar as an application to Wounds and Ulcers.
He finds that commercial beet sugar is practically sterile. It was free
from pathogenic germs, and in the few cases where growth occurred,
only harmless saprophytic organisms developed. He applies the dry
sugar directly to the wounds, and finds that it is unirritating, while it
acts as an efficient deodorant. It rapidly dissolves, and then exerts
considerable osmotic attraction, causing a profuse secretion of serum
which flushes out the wounds and prevents the dressings from becoming
adherent. It also seems to have the property of dissolving fibrin. As
a result the wounds clean i*apidly, are free from odour, form healthy
granulations, and epithelialize in a short time. He states that it is
specially valuable in promoting rapid healing of drainage Sinuses ;
large septic wounds also do well, but tuberculous wounds do not. His
experience extends to over 100 cases treated in the Marburg surgical
wards.

Reference. — ^ Munch, med. Woch. 1913, 4or».

SULPHUR.

Vorner^ describes a new method of applying sulphur to the skin.
A concentrated solution of potassium sulphuratum, containing 50 grams

THERAPEUTICS

3 ^

THYMOL DERIVATIVES

in 100 c.c. of water, is painted or rubbed over the diseased skin and
allowed to dry. The parts tinged yellow are now sprayed with acetic
acid vapour or moistened with 5 to 10 per cent acetic acid, which
decolorizes the skin and leaves a fine powder adherent to it. This
method is suitable for reducing hyperaemia and producing dryness of
the skin, and is especially useful in Acne Rosacea, Seborrhoea Oleosa,
and Eczematous or Follicular Processes depending on these causes.
An ointment suitable for antiparasitic action in Seborrhoea Sicca,
Impetigo, and Parasitic or Fungous Infections is prepared as follows :
In one kilo of fat, 2 to 2*5 grams sulphur are dissolved at 50° to 100° C. ;
then 50 to 55 grams oleum sulphuratum are added, and lastly 40 to 50
grains freshly precipitated and filtered calcium sulphide, dried with
absolute alcohol, are added and thoroughly mixed. This can be used
pure or diluted with boric ointment.

Reference. — ^Munch. med. Woch. 1912, 1909.

SUMBUL.

Macht^ has studied the action of the tincture of sumbul in a series
of 100 neurasthenics exhibiting many varieties of functional nervous
disorders. The results were not good. The same holds true in disorders
of the menopause. He concludes that it has no specific action in the
menopause, and that the ordinary commercial sumbul on the U.S.
market is an inert, useless, and needlessly expensive drug, which should
be removed from the pharmacopoeia.

Reference. — T//^r. Gas. 1912, 764.

THYMOL DERIYATIYES.

Bachem^ publishes notes on two new thymol derivatives. Thymo-
CHa

HC ''"\COOH

tinic acid occurs in white cry.stais insoluble in cold, slightly

Cj’Ht

soluble in hot water, soluble in acetic acid, alcohol, ether, chloroform,
benzol. It is readily absorbed, and is not toxic for rabbits in doses of
2 grams. It is a fairly strong antiseptic. Thymacetol, the acetone
ester of thyniotinic acid, is a white crystalline powder, insoluble in water,
but soluble in organic solvents and in animal and vegetable fats. It is
relati^’ely non-toxic for rabbits, and is absorbed when rubbed on the
unbroken skin. It possesses antiseptic properties, but of more interest
is its anaesthetizing action. The rabbit's cornea is anaesthetized
completely in two or three minutes, the effect gradually passing off in
half an hour. Bachem suggests, as worthy of clinical investigation as
a Local Anaesthetic, a 10 per cent solution of thymacetol in ethoxy-
propionic-menthol ester, which is also a fairly strong non-toxic local
anaesthetic. Thymacetol, he suggests, might be used in Wounds and
Ulcers when nerve-endings are exposed, while the menthol-ester
solution might be tested in Irritable Conditions of the Throat

Reference. — ^Berl. klin. Woch, 1912, 2086.

TRYPASAFROL

MEDICAI.,ANNUAL

TRYPASAFROL.

This dye, belonging to the safranin series, has recently been suggested
as a trypanocidal agent worthy of trial in man. Ritz's^ investigation
of its trypanocidal action in experimental trypanosomiasis in mice
shows that it is relatively feeble as a trypanocide, and therefore not
likely to be of use in human trj^panosomiasis.

Reference. — ^BerL Mlu. Woch. 1913, 13S7.

TYRAMINE. {See also Ergot.)

Hoyt,^ after testing the therapeutic action of this preparation, states
that it is uncertain and slow in its action on the circulatory system
when given by the mouth. In doses of 20 to 40 mgrams it produces
a marked and abrupt rise of blood-pressure, which is very fugacious and
sometimes accompanied by irregular heart-action, with slowing of the
pulse. The drug cannot be depended upon for a prolonged action, but
may be of use in cases of temporary vasomotor depression.

Reference. — Kimer. Med. 1913, ii, 76.

UREABROMINE,

This preparation, calcium bromide urea, CaBr .j, 4 CO(NH3)2, contains
36 per cent bromine. Johannessohn^ has found it a useful sedative
which in several cases controlled Motor Spasms. It also acts well in
pure Nervous Excitement of Cardiac Disease associated with rapid
pulse, and in Nervous Sleeplessness.

Reference. — ^Deut. med. IVoch. 1913, 268.

URINARY ANTISEPTICS. {See also Hexamethylenetetramine.)

Jordan,^ in an interesting article, describes cxpex'iments planned to
estimate the antiseptic action of various drugs reputed to be urinary
antiseptics. By the administration of acid phosphate of sodium, or
alkaline citrates, the reaction of the urine was varied. As tests of the
antiseptic action, he noted the development of putrefaction and the
growth of staphylococci and B. coli in the urine passed after administer-
ing the urinary antiseptic. The serum was sterilized by passage
through a Chamberland filter before being inoculated with the test
organisms. His conclusions are as follows: —

The acidity of the urine is readily increased to an extent of more
than double the normal by acid sodium phosphate, and to a consider-
ably less extent by benzoates. With large doses of citrates it is easily
rendered alkaline. Putrefaction of the urine, and the growth of the
staphylococcus, is aided by alkalinity and delayed by acidity in propor-
tion to the amount thereof. The reverse is the case \vith B. coli, but
only to a small extent.

“ Hexamethylenetetramine is not itself antiseptic, but acts by pro-
ducing formaldehyde in the urine. This only takes place in acid urine,
and the drug is inert in alkaline urine. The degree of antiseptic power
is proportionate to the acidity, and where this is normal or increased,
the drug is far the most efficient of all the urinary antiseptics. Despite
its undoubtedly different behaviour in the test-tube, there is no evidence

THERAPF.CTICS

VACCINES

that helniitoi acts differentiy from hexamethylenetetramine in the urine,
and this remark applies also to citramine, hetraline, and cystopurin.

“ Sandalwood oil is a bad general antiseptic, but appears to have a
specific action on the staphylococcus which may apply to cocci generally.
It is of some use in alkaline urine. Benzoic and salicylic acids are very
similar in action. Both are fairly efficient antiseptics in the urine, but
are of very little use in alkaline urine. Boric acid is an efficient anti-
septic. Its action is unaffected by alkalinity, so that it is the most
efficient drug in alkaline urine we possess. Uva ursi is quite a good
antiseptic. Its action is ceidainly not due chiefly to the arbutin it
contains.’'

The following are, he thinks, legitimate practical deductions. “ The
use of urotropin (together with acid sodium phosphate, which should
always be given with it) as a proph^dactic before any operation or proce-
dure where the urine ma^^ become infected is of the utmost value, since
if the urine is clean and highty acid, and sufficient urotropin is given in
small doses to keep it continually present, the urine will not support
the life of any organism, and becomes indeed a powerfully antiseptic
fluid. Uroti'opin should only be given where the urine is, or can be
made, acid, otherwise it is inert. It should never be given with potas-
sium citrate in J 5 , coli infections. If it is desired to try the effect of
making the urine alkaline in these conditions, use boric acid and uva
ursi infusion.”

l^EFERENCE, — Med. Jour. 19x3, ii, 648.

UBOTROPIN- — {See Hexamethyeenetetramixe, Urinary Anti-
septics.)

UZARA.

Eisenheimer^ adds another to the series of favourable reports on
Lizara as a useful drug for controlling Diarrhoea. It acts well in all
forms, but he specially mentions its use in the diarrhcea of Typhoid
Fever and Dysentery, and in diarrhoea following Food Poisoning. As
a rule, he gives 20 to 30 drops of the 2 per cent solution every two hours,
but he has also used tablets and suppositories. After eight or ten doses
the tenesmus of severe diarrhoea ceases, though the stools may still
remain frequent. Usually, on the second or third day, the motions
become firmer and the diarrhoea ceases.

Reference. — med. Woch. IQ12, 2415.

VACCINES.

Moore Alexander,^ discussing the use and abuse of vaccine therapy,
summarizes the chief bacteriological errors that cause failure as follows :
the want of early and accurate diagnosis, the use of stock vaccines in
undiagnosed conditions, and administration without any regard for
the reaction, the interval, or the progress of the patient’s immunity.

Stone^ also insists on the necessity" of accurate knowledge of the
bacteriological condition present. Speculation should not enter into
the consideration of the rational w’orker, Thiis^he objects to the use of

VACCINES

MEDICAL ANNUAL

rheumatism pltylacogen ” in acute and chronic rheumatism. The
exact bacteriological conditions are unknown, and the use of such a
mixture of the metabolic products of a number of strains of pathogenic
bacteria is a shotgun mixture with no scientific basis. As regards the
use of tuberculin, he is rather sceptical. He is not satisfied that
patients treated with it improve in the aggregate any more than those
receiving none. He has repeatedly seen harm result from the indis-
criminate use of tuberculin. There is also the difficulty of knowing
which type of bacillus is producing the tuberculous lesions. In any
case, if tuberculin is used, it is decidedly better to employ the small
doses advocated by Wright, as they have the merit of comparative
safety. The most suitable type is the chronic case with good nutriton
and no complications. Though he has had a few good results with
vaccine therapy in streptococcic septicaemia, he is not convinced that
the results obtained by vaccines will be any better than with anti-
streptococcic or streptolytic sera or normal human serum. Possibly
the most gratifying results in bacterial therapy are obtained in localized
Staphylococcic Lesions. In localized Gonorrhoeal Infections he thinks
that vaccines help. Vaccines prepared from freshly isolated strains
do not seem to give such good results as older strains, and there is no
advantage to be obtained from autogenous strains. For diagnostic
purposes an injection of vaccine will often differentiate the gonococcal
lesion by the resulting reaction ; but care must be exercised, as he has
seen epididymitis follow on an excessive dose. He thinks that the
prophylactic use of vaccines is of value in many conditions.

Ellern*^ has used Wright’s pollen extract in 13 cases of long-
standing Hay Fever. The results were fairly good. None of the
patients were entirely cured, but only 2 felt that they had not
obtained benefit from the treatment; 5 were improved, and in the
remaining 6 cases the improvement was very marked. The impor-
tance of these results is, however, considerably discounted by the fact
that last year was apparently not a severe one for hay-fever sufferers,
as 20 patients who did not receive the vaccine treatment reported
that they had suffered less than usual. Only 4 stated that they had
been as bad as usual, 14 had been better than in the previous
year, and 2 stated that they had been greatly better.

SilP reports good results from the use of vaccines in ten cases of
Erysipelas in Infants. He considers that streptococcus vaccine is by
far the most efficacious treatment at our command in this disease.
Large doses at intervals of twenty-four hours should be used.

Szily^ has obtained very satisfactory results in the Multiple Cutaneous
Staphylococcic Lesions of infants.

Wynn® has had good results from the use of vaccines in various types
of Septicaemia. In fifteen cases of ulcerative endocarditis in which
a streptococcus was isolated from the blood, vaccine treatment proved
unsuccessful. In several cases temporar^^ improvement was seen, but
it was not maintained. In other types of septicsemia the results were
more satisfactory, notably in Puerperal cases and in Infections with

THERAPEUTICS

VACCINES

B. coli. The cases all seem to have been severe. The ei^ect of the first
or second dose of vaccine was usually sho%\Ti by an alteration in the
type of temperature, which often became intermittent where it had
previously been remittent or maintained at a high level. Associated
with this, subcutaneous abscesses frequently formed rapidly, but these
might subside without suppuration, apparently an attempt on the part
of the organism to localize the disease. The change of temperature is
a good sign, and if it does not occur with the first inoculation the dose
should be raised until it does.

Fisher" points out that Common Colds are unquestionably due to
infection by micro-organisms, and are contagious. They can be largely
prevented by reasonable isolation of each case, and preventive
inoculation which aborts or shortens the disease. He uses a stock
vaccine containing man3^ different strains. The dosage which seems
to give the best results sxe Pneumococcus, M , catarrhal? s, M. ieiragemis,
125 million of each ; Streptococcus, 50 million ; B, inflnenzcB, B. septus,
B. FriedVdnder, about 100 million ; Staphylococcus, 400 to Soo million.
The patient’s owm autogenous strain may be added to the stock
vaccine. The vaccine should be so prepared that the dose is contained
in 8 minims. Four or five injectio' s at weekly intervals in increasing
doses usually give sufficient immunity to last for several months.

Hirschfelder® has used digestive bacterial extracts in Gonorrhoeal
conditions with a fair degree of success. A suspension of the gonococcus
was heated to 38° C. ; to it was added an equal quantity of 0*2 per cent
solution of pancreatin with 2 per cent sodium bicarbonate, which was
allowed to act at 38° C. for fifteen minutes and then acidulated with
hydrochloric acid to stop the action of the ferment. The mixture,
filtered through a Pasteur filter, was then ready for use. The usual
dose was 5 c.c. intramuscularly, which is in most cases followed in a few
hours by a reaction, chill, malaise, and fever. Often succeeding doses
produce less reaction, and the dose may be increased. In gonorrhoea,
fairly good results \vere obtained in females, but the results in males
were less distinct. Thus, in one series of 20 prostitutes treated wdth
vaccine and the usual methods, in iS a rapid cure was obtained, in 10
cases after one injection, in 6 after two, and in 2 after three injections.
Five out of 7 cases of epididymitis recovered raj>idly and 7 cases of
gonorrhoeal rheumatism ^vere also cured under vaccine treatment.

Ross^ has an important paper in which he summarizes his results
obtained in over 400 cases of acute and chronic infectious disease. This
series of cases received treatment at St. Thomas’ Hospital during the
three years igoS-igii, Starting at first with full doses at intervals
of ten days, this was found to cause a good deal of constitutional
disturbance, and it was found advisable to administer smaller doses
intramuscularly every five days, as the local and constitutional
disturbance was thereby lessened. As it seems likely that the anti-
bodies are formed locally at the site of injection, this was changed as far
as possible at each dose. As a rule a course of six or eight injections
was given. The average dose in millions was Staph, albns 100 to 200,

VACCINES 36 MEDICAL ANNUAL

Staph, a ureas 30 to 130. Streptococcus pyogenes 3 to zo, Pnemnococcus
3 to 10, Gonococcus 3 to 5, B. coll 50 to 150, B. typhosus 500 to 1000,
B. acnes 5 to 10.

Furunculosis was amenable to vaccine treatment ; out of 80 cases,
60 per cent were cured and 15 per cent improved. Stock vaccine
did well, provided it was not over three months old and made from
the pure culture isolated directly from the tissues. Laboratory sub-
cultures are very inferior. If the stock vaccine produces no improve-
ment with three or four inoculations, an autogenous vac.cine should be
prepared. Acute infectious bone disease was not so favourably
intluenced as furunculosis by vaccine treatment. Vaccine only acts
as an adjuvant, and no case should be treated with it till surgical means
have been tried. Small doses of vaccines are sometimes useful when
there is an unsatisfactory healing response after operation ; but
Acute Osteomyelitis, with threatening pyaemia, is one of the most
difficult problems for the vaccinist to face. Ross advises the use of a
good stock vaccine made from an acute bone case. As soon as the
temperature drops, vaccine treatment should be stopped. Sequestra
must, of course, be removed. When the staphylococcic infection is
secondary to psoas abscess, the case is unsatisfactory for vaccine treat-
ment. Cases which do well after operation should be left alone, but
sometimes, when they do not improve after opening and drainage,
vsccines do good.

In Carbuncles, vaccine treatment seems to assist surgical measures
in promoting cure, clean granulations forming sooner and the sloughs
separating quickly. Infections with Staphylococcus alhus are chiefly
represented in his series by Acne Yulgaris. Treatment with mixed
stock vaccines of Staph, aureus and B. acnes gave good results, 19 out
of 27 cases being cured. Though relapses are common, renewed
treatment is again satisfactor^L Pneumonia was not appreciably
affected by vaccine treatment, which should only be used with extreme
caution. Neither was it very successful in pneumococcal empyemata,
but it was satisfactory in Pneumococcal Arthritis.

Out of 48 cases of streptococcic infection, the best results were
obtained in Cellulitis and Abscesses. There was no benefit in two cases
of malignant endocarditis. Three cases of Suppurative Arthritis were
cured and one improved out of a series of five. Twenty-three cases
of Erysipelas treated with fresh stock vaccines (not over a month
old) made from erysipelas cases, led the author to conclude that it
has no specially good effect, and is mei-ely an adjuvant to other
methods.

In 22 cases of Coli Bacilluria, vaccines produced a cure in 7 and
improvement in ii. In 5 out of 8 cases of Appendicitis where an
obstinate faecal fistula had formed after operation, the administration
of a B. coli vaccine certainly resulted in benefit ; but cases of dysentery
and colitis were unsatisfactor}^ in their reaction to the treatment. In
Gonococcal Infections, vaccine treatment caused considerable improve-
ment as regards pain, but w?s less advantageous in increasing mobility

THERAPEUTICS

WORMSEED OIL

and freer use of the joints. Nor was it easy to say how far the benefit
was due to associated forms of treatment.

Sensitized Vaccines. — Gordon’*'^ reports an interesting series of cases
in which these apparently gave good results. His series consists of
19 cases of Streptococcic Infection. In twelve of these the vaccine
produced great improvement though at least six had received ordinary
surgical and medical treatment in vain and were in a serious condition
when it was used. Three had streptococcaemia. When the vaccine
was given, the general and local condition improved, temperature fell,
and the patients began to get well. Gordon used a stock vaccine,
consisting of three to five mixed strains, sensitized, and then killed with
phenol. He gave increasing doses subcutaneously, usually commencing
with 100 millions and rising rapidly to 500 and 1000 millions. His
general conclusion is that any power of re.sistance latent in the patient
is rapidly awakened by the use of sensitized vaccine, even at a compara-
tively late stage of the infection. He suggests the prophylactic use
of sensitized vaccines before operative procedures and in the face of
epidemics.

McLean^^ reports a case of subacute rheumatism, in which the
intravenous administration of rhciimaiism pliylacogen was apparently
fatal. Within forty minutes of the injection the patient had a prolonged
rigor, with delirium, vomiting, and weak circulation. For the next
seven days he passed very little urine, and eventually developed a
terminal hypostatic pneumonia.

jMcCalh- has had good results from phylacogen treatment of “ Chronic
Rheumatism,” Rheumatoid Arthritis, and chronic Gonorrhoeal Infections.
Out of a series of 30 cases the results were highl}^ satisfactory except
in 2.

Referexces. — ^Liverp. Med.-Chir. Joitv. 1913, 19S ; -Jour. Jmer. Med.
Jssoc. 1913, i, 189; '^Veuf. mcd. Woch. 1912. 1590; ^Mcd. Rec. 1913. i, 573 ;
^•IVien. kliu. Woch. 1912, 1739; Jour. 1913, Apr. 49; "East. ^Icd.

and Suvg. Joir/. 1913, i, S34 ; ^Jour. Aniev. Med. Assoc. 1913. i. io6r ; ^Pract.
1913, ii. 96 ; ^^Lancet, 1913, i, 1801 ; Awer. Med. Assoc. 1913. i, 5SS ;

'^-Lancet, 1913. ii, 432.

WORMSEED OIL.

It is difficult to disguise the taste of this anthelmintic oil (oleum
cheuopodii aiithelininthici) , but it can be most readily given as an
emulsion with castor oil. A German preparation of this kind called
wermolin has been successfully tested clinically by Briining against
Round-worms in children. It acted well if followed in two hours by a
simple purge.

Reference. — ^Deut. med. Woch. 1912, 23GS.

RADIOLOeV

MEDICAL ANNUAL

RADIO-ACTIVITY AND ELECTROTHERAPEUTICS.

CHARLES THURSTAN HOLLAND, M.R.C.S., Etc.

Ifon. Mfd. Oj^icer /a Electrical Department, Liverpool Royal In/t^inaiy ; P7esidcnt 0 /
the Elecbo-Tkerapeidic Section, Royal Society of edict /u\

The feature of 1913 from the point of view of radiology is that, for
the lirst time at an International Congress of Medicine, there was a
separate section for this branch of work. Under the presidency of
Sir James Mackenzie Davidson its justilication was its success. In
addition to numerous and valuable papers on all the important branches
of A'-ray diagnosis and treatment, there were reports and discussions
on the .v-ray examination of the thorax, the radiography of the stomach
and intestines, a joint discussion with the gynaecological section on the
uses of A'-rays and radium in gynaecological conditions, and a discus-
sion with the orthopaedic section on the value of ,r-rays in various
conditions of bones and joints. Full reports of all the papers and
discussions will be published in the “ Proceedings of the Section,
and to this we would refer our readers for much valuable infonnation.

The year has also been noticeable for the very marked advance in
the recognition of the value of radium in the treatment of disease,
and a corresponding demand, evidenced especially in England and
Germany, that the hospitals of both countries should possess sufficient
quantities to deal efficiently with the cases which require such treat-
ment. As it is now possible to collect in glass capsules definite
measured doses of the emanation from radium, and. use these for
treatment — ^the effects being exactly the same as if the original radium
itself were used — larger numbers of cases can be dealt with at the
same time.

One of the most striking papers read at the Congress was by Abbe,-*
of New York, who detailed the results of his experiments upon plant
growth after the seeds had been exposed to larger or smaller doses of
radium, the chief points being (i) That, according to dosage, he obtained
two effects, one being to stimulate and the other to retard growth ;
(2) That the distance of the radium, without filtration, from the parts
exposed, had a marked result upon the effects produced. The first of
these findings has an important bearing on the suggestion which has
been advanced, that some cases of malignant disease have taken on
a more rapid growth after exposure to radium ; and the experiments
seemed to indicate not only the reasons for this but also — and this is
of the greatest importance — ^the lines on which the treatment should
be conducted in order to avoid such a result.

References. — Trans, Rad. Section ijth Inti. Cong.. of Med . ; ^Ibid. and
Brit. Med. Jour. 1913, ii, 910.

PLATE 1.

The two gall-stones show below the outline of the kidney, and each has a distinct dark edi

C, Thurstan Holland

MEDICAL ANNUAL, 1Q14

THERAPEUTICS

X-RAY DIAGNOSIS

NEW APPARATUS.

Three instruments were shown at the Congress exhibition, marking
a distinct advance in .v-ray instrumentation.

Messrs. Siemens Bros, showed a large iransformer on the lines of
the Snook machine. It was so arranged that on the one hand the
smallest possible current could be used for tube excitation ; and on
the other,' by a very simple adjustment, an enormous single-pulse hash
could be obtained for the most rapid radiographic exposure.

The Veifa Works had on exhibition Dessauer's x-ray Biogmph.
This is a mechanical plate-changing machine enabling eight separate
plates to be automatically jilaced in position and exposed in about
one second ; it also allows of the automatic exposure of the plates in
rapid or slow succession, or separately at any desired moment.

The same fimi also showed a stereo-fluoyoscope, by means of which
the image is seen stereoscopically upon a fluorescent screen.

X-RAY DIAGNOSIS.

Radiography of the Abdomen. — Two papers mark a step forward
in the radiographic diagnosis of gall-stones. Thurstan Holland,^ in
three cases, succeeded not only in showing gall-stone shadows, but in
their interpretation as being different from those of renal stones and
other conditions giving abdominal shadows. Although the negative
diagnosis by .r-rays is never possible, a positive result should be
obtained with much greater frequency than has hitherto been considered
possible. One feature of gall-stone shadows in a large percentage of
the cases in wdiich they can be shown is that the circumference, owing
to lime salts being deposited upon the surfaces of the stones, is much
more opaque than the central portion, and thus the shadows are very
often either annular or dark-edged (Plate I). Case^ records remarkable
success in this method of diagnosis, and has shown gall-stones in
40 cases out of 1000 sent to him for stomach examination. He
lays much stress upon the value of stereoscopic A^-rays in making
the differential diagnosis, and publishes some remarkable examples.
His opinion is that if suspected cases were examined systematically,
they should be shown in from 40 to 50 per cent of those in which they
were actually present. He advises moderately soft new tubes, and
instantaneous exposures.

The importance of these papers lies in the fact that it has been
generall^r considered by radiographers for some years that the exam-
ination in suspected cases is scarcely w^orth making, owing to gall-stones
showing so rarely. In view of the modem improvements in technique,
etc., and the above results, systematic A'-ray examination should be
carried out in future.

The Liver itself can be examined radiographically. Jaugeas®
describes anomalies of situation, changes of volume, an‘d anomalies
of form, all made out by a screen examination. Hypertrophy and
atrophy can both be demonstrated, whilst in many cases the altera-
tions due to hydatid cyst or abscess are clearly indicated.

X-RAY DIAGNOSIS

MEDICAL ANNUAL

I'he Stomach . — Thurstaii Holland^ describes a new technique for
obtaining- a radiograph in any particular stage of its contraction.
Noting on the screen the exact phase required, the number of seconds
is counted between the stomach being in this condition and resuming
it once more. As a rule this is 20 seconds, rarely more, sometimes
from I to 4 less. To obtain a plate at the exact moment, proceed
as follows : Start a stop-watch at the time the stomach presents the
required shape, place a plate in position, and then expose at a multiple
of the number of seconds noted. The whole operation need not take
more than from one to two minutes, and experience has shown that
it is almost always successful. The chief t^alue is that a picture of the
varying pyloric end can be made with exactitude at any particular
moment which is desired.

The same author^ calls attention to the radiographic appearances
in a case of Hair Ball in the Stomach [Plates 11 , III). In this case, the
nature of a large tumour in the upper abdomen was quite uncertain,
and was not suspected as being gastric until the ,r-ray examination
showed this to be the fact. The barium food — a thin emulsion — was
observed to flow into the stomach and coat the walls, the shape of the
organ being beautifully defined. It was difficult to account for the
two dark bands of shadow crossing the stomach ; at the operation
three distinct hair balls wdiich articulated upon one another with
facetted surfaces, were found and removed ; the dark bands were
caused b}^ the food flowing between* these facetted surfaces. The
author points out that in this case, in which the hayr-balls filled the
entire stomach, the organ shows the J -shape described by radiologists.
A case of a similar description is recorded by Barcla}^^ in wffiich the
exact diagnosis, unsuspected beforehand, was demonstrated by radio-
graphy. He very iitgeniously dilated the stomach with carbon dioxide,
when the upper end of the hair ball could be pushed up into the large

magenblase ’’ and easily seen. Again, the shape of the hair ball
corresponded almost exactly to that which radiologists consider to be
the normal stomach.

Franz GradeF points out that the rate of emptying of the normal
stomach is much faster with the barium sulphate meal than with the
bismuth meal. He claims that it is twice as fast. On the other hand,
his experiments show^ed no difference in the motility of the large
intestine. He advocates the use of barium sulphate in preference to
bismuth, and states liis reasons for this. [These observations on the
rate of emptying of the stomach must be accepted with reserve. In
a very large number of uases examined with barium during the past
eighteen months, the waiter has noted no difference whatever in the
motor times of the stomach as compared with the cases receiving
bismuth.— C. T. H 1

Mixter® describes the A'-ray appearances in Congenital Hypertrophic
Stenosis of the Pylorus as seen in four cases. The chief point is that the
pyloric end maintains a rounded, prow^-like appearance, whilst the
bismuth food assumes a dense ball -like mass at the most dependent

PLATE II.

Skiagraph of three hair Ijalls in the stomach. Appearance after giving emulsion of
barium sulphate.

C. ThitJstan Holland

MEDICAL ANNUAL, IQ14

TH1*RAPF.UTJCS

X-RAY DIAGNOSIS

position of the greater curvature ; and that this condition will often
remain unchanged for hours. His paper is illustrated with a series of
splendid radiographs taken at intervals after the meal ; and also a
number showing the results of operation, immediate, and as much as
three years later. In one case, three years after the operation the
stomach was seen to empty itself in as short a time as fifteen minutes
after a meal, and yet the nutrition of the child was unaffected.

Haudek® makes some interesting observations on The Diagnostic
Value of Gastric Antiperistalsis, which has hitherto been looked upon
as confined to cases of pyloric stenosis. From an examination of sixty
cases in which it was observed on the screen, and in which an operation
had later been performed, he found that it was always associated with
pathological alteration of the stomach wall, most frequently, but not
invariably, with pyloric stenosis.

Pfahler/^ in an interesting paper on the value of the ,r-rays in Gastric
Ulcer, is of opinion that retention of food in the stomach after six hours,
if not accompanied by tumour formation or in an otherwise normal
stomach, is one of the most valuable signs of acute or liorid ulcer.
Retention may occur in gastric ulcer when the stomach outline and
the peristaltic waves are quite normal.

Barclay publishes the results of his examination of a large series
of cases in two articles on Gastric and (Esophageal Affections, too long
to be reviewed in detail, but full of original observations and sugges-
tions. (')n one point he is quite clear. “ The more time one spends
on a case, and the more one considers the A'-ray findings in connection
with the clinical history, the more accurate will be the diagnosis.
The A"-ray method is of some value by itself, but when it is taken in
conjunction with all the other available means of investigation, it
becomes the greatest of all aids Ave possess in the diagnosis of diseases
of the walls of the intestinal tract.”

Anderson relates a case in which Enteroliths gave an ,r-ray shadow
and caused difficulty in diagnosis. Two were present as a tumour
in the region of the caecum, and cast overlapping shadows over the
iliac bone. They were removed by operation. Calcium phosphate
in the nucleus and capsule of each rendered them opaque to ^r-rays.
Rochet, Gayet, and Arcellin^^ also call attention to this rare condition,
quote several cases, and point out that the shadows show no special
characteristics, and ma}^ be mistaken for renal calculi, leading to
errors in diagnosis. They have found these bodies in the appendix,
and also in the ascending colon. In their cases also, calcium phosphate
was the cause of the A-ray opacity.

Intestinal Stasis. — ^This subject has attracted much attention lately,
a fact largely due to the .r-ray observations and the deductions there-
from of different observers. Jordan'^^ lays down the laAv that the
discovery of a static duodenum is a certain indication that other
evidence of intestinal stasis exists in the ileum and large intestine,
and that, vice versa, a normal duodenum is a sign that intestinal stasis
is not likely to be present. He is of opinion that the duodenum is

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undoubtedly the most sensitive point in the alimentary tract, and its
indications must be regarded as of the utmost value in diagnosis.
Duodenal ulcer is a late stage in the process of bacterial infection,,
owing its origin to intestinal stasis. Hertz d®' on the other hand,
disagrees entirely with the above conclusions, and in a series of fifty
cases of uncomplicated duodenal ulcer has never seen a dilated duo-
denum or a duodenal kink ; and he goes on to say that the constipation
(or intestinal stasis) which is generally present in cases of duodenal
ulcer, is not its cause, as in many cases it only develops after the
symptoms of ulcer have appeared, and it almost ahvays disappears as
soon as the ulcer heals, whether as a result of medical treatment or of
the performance of a gastro-enterostomy. Pfahler,^® a very acute
and reliable .r-ray Avorker, has only seen constriction of the terminal
portion of the duodenum three times, and a constriction of the terminal
portion of the ileum (Lane's kink) a few times. [Jordan says that ‘'in
order to demonstrate ileal kink in these cases of intestinal stasis, no
medicine to act upon the bowels must be given for two days previously
to the ,r-ray examination, and that as much as 6 oz. of bismuth
carbonate must be given with the test meal.” Accepting this, it is
obvious that he starts with the large bowel full of food, and that the
copious bismuth meal, finding some difficulty in ever getting into the
colon is, so to speak, dammed back in the last loops of the small bowel.
Therefore, if this technique is necessary in order to see the kink, and
it cannot be demonstrated if the large bowel is first of all cleared out,
and onty the usual 2 oz. of bismuth is given, it seems obvious at any
rate that the kink in the ileum has no direct relationship to the stasis,
and does not in itself even cause any delay in the small bowel.
--C. T. H.]

The Thorax , — ^The value of a radiographic examination of the lungs
in the diagnosis of Early Phthisis has been considerably enhanced since
the improvement in apparatus has made possible the taking of instan-
taneous radiographs of the chest. Wenckeback^"^ lays special stress
on this fact, and also urges the importance of the stereoscopic method.
He asserts that the two together have revolutionized the methods of
chest examination so far as the prompt diagnosis of early phthisis is
concerned. Riviere^® points out that radiography goes far to confirm
the opinion that phthisis is only the final stage of a childhood infection,
inasmuch as it discloses as a rule, old disease of bronchial and pulmonary
glands, and also shows that in these cases the disease appears to spread
round the bronchial branches into the lung, and especially towards the
apex. He advocates the x-ra,y examination in conjunction -with other
methods as helping to confirm the diagnosis in doubtful cases, giving
great assistance in determining the extent of the disease, and helping
to show whether or not the other side is free.

Lawson’-® says that experience has not only substantiated the ;t'-ray
claims of sixteen years ago, but exalted and glorified them, until now it
may be said that the consultant who, in the diagnosis of a difficult
and obscure lung condition, has not brought them to his aid, has

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failed alike in his duty to himself and to his patient. In his opinion,
in an early doubtful apical pulmonary lesion, a screen examination
invariably shows restricted diaphragm movement, less translucency,
and a failure to light up at the apex on deep respiration, if early
phthisis is present. This paper should be read by all interested in this
branch of work, as the author writes both as an expert physician and
a radiologist.

Maragliano^*^ is of opinion that a valuable .r-ray sign, especially in
cases of small Pericardial Effusion is that the pulsation shadow of the
inferior border of the heart, when it touches the clear area due to gas
in the stomach, almost or entirely disappears. He has tested this in
eight cases, and found that after tapping the pericardium, the pulsations
could be seen to return after the sac was emptied.

Intrathoracic Aneurysm is discussed in detail by Havilland Hall^'
from all points of view. The paper is well illustrated by diagrams and
radiographs of much value, and the diagnosis by radiography is fully
mentioned. {See also Aneurysm, Intrathoracic.)

Bony Conditions , — Elmslie,^^ under the title of “ The Diagnosis of
Endosteal Tumours,” discusses very fulty the .r-ray appearances in
abscess, gumma, cysts, osteitis, enchondroma, and various malignant
diseases. A collection of fine radiographs illustrates this paper, and
is of especial value in affording the reader the opportunity of comparing
the appearances of the various conditions. This paper should be read
in connection with another by the same author^^ on fibrous and fibro-
cystic osteitis. In both communications the ;ir-ray findings are described
in detail, and the explanation of the site-occurrence of benign cysts of
bone, which are much more common than is generally known, is veiy
interesting. It is made quite evident that, whilst a radiograph is often
absolutely diagnostic, on the other hand, in many cases great difficulties
of interpretation occur, and that sometimes the diagnosis cannot be
made by radiography alone. Shoop^-* shows the value of an ;t'-ray
examination in a case supposed to be osteo-sarcoma of the humerus.
The absence of bony structure in the hard mass, together with no
thickening or enlargement of the bone itself, pointed to gumma, and
though syphilis was denied, antisyphilitic treatment resulted in
complete disappearance of the tumour.

In intimate connection with these j)apers is one by Coley,-® on
Myositis Ossificans Traumatica, a full report of three cases illustrating
the difficulties of diagnosis from sarcoma. Here again, the radiographs
alone might be distinctly misleading, especially those taken at the first
examination, and the radiographic interest is that the author publishes
.r-rays showing the condition of the disease at different periods of time.
In myositis ossificans, the sharp outline corresponding to the junction
of the tumour with the bone, is always present, while in sarcoma it is
less distinct, except in the very early stages of the disease.

Skillern and Pfahler®® maintain that are a great aid in the

diagnosis of diseases of the Sphenoid Sinus. Pfahler lays stress upon
the necessity of good technique and good negatives. Proper interpre-

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4 ^

MEDICAL ANNUAL

tation of the plates is essential, and as a rule, disease of these sinuses is
associated with an exudate which diminishes their ,r-ray transparency.
Ih’own-^ also Avrites upon the same subject, and includes a description
of the radiographic changes in diseases of other sinuses, and in the
pituitary region. This paper is well illustrated. He is of opinion that
the key to success lies in the highest technique and the study of stereo-
scopic radiographs.

Kidney. — Shenton^^^ still maintains that the screen examination is
more reliable than plate exposure in the examination for stone in the
kidney, and still more so since the introduction of the Snook high-
tension generator.

Kelly and Lewis'-'^ recommend a new medium for skiagraphy of the
urinary tract, namely, silver iodide emulsion. They claim for it that
in a 5 per cent solution it is (i) cheaper than coliargol, (2) fully as dense
as a 10 per cent coliargol solution, (3) bland and entirely unirritating,
(^) non-staining, (5) stable if the emulsion is well prepared. As it is
insoluble in water it must be suspended, and mucilage of quince seed
is suggested as the best medium. Reynard and Nogier^^ warn against
the possibility of coliargol injections leading to a wrong diagnosis,
and relate a case where, after the injection, a dark shadow led to the
opinion that there Avas a stone in the renal pehns. At operation no
stone was found, and they suggest that the shadow A\'as due to the
extremity of a Malpighian pyramid, rather larger than usual, so
situated that it did not alloAA’ the coliargol to fill the AAdiole of the renal
pelvis uniformly.

Pseudo-calculus of the Kidney is also discussed by Ponzio,®^ and
various causes are described. The most unusual Avas a sliadoAv as large
as a hazel nut, due to a shell of calcareous matter intermingled with
osseous substance, and enclosing a blood-clot. Histologically it showed
the characteiistic structure of a large vein, and it was attached to the
inner wall of the renal cavity in a cystic kidney. OllerensliaAV^- draws
attention to the fact that stones may be found in the kidneys of quite
young people, and publishes two cases where v-rays, and subsequent
operation, showed a stone in the kidney of a girl aged 3 years, and in
that of a boy of S years.

Belfieid'^® has incised the vas deferens just above the testicle, injected
a coliargol solution into the vas and vesicle, and taken radiographs.
He claims to have shown (i) A peristalsis of ampulla and vesicle into
the prostatic urethra Avithout emission ; (2) Sphincteric closure of
ampulla and vesicle ; (3) A not infrequent occlusion of the ejaculatory
duct, coUA'^erting A^as and A^esicle into a retention cyst. A 10 to 15 per
cent solution of coliargol is strong enough, and not more than 4 or 5 c.c.
should be injected.

References. — ^Arch. Ronigen Ray, 1913, i, 374 ; -Ibid, ii, 135 and Jour.
Amer. Med. Assoc. 1913, ii, 920 ; ^Arch. Ronigen Ray, 1913, it 48 ; '^Ibid.
gS ; ^Ibid. 46 ; ^Ihid. iby ; "^Ibid. i, 420 ; ^Bosf. Med. and Surg. Jour. 1913,
ii, 309; '^IVien. nied. Woch. 1912. No. 16; ^^Anier. Quart, of Rontgenology,
19x3, Feb. ; '^'^Med. Chron. 1913, iSS and 2^9 ; ^-Brit. Med. Jour. 1913, i, 931 :
^'^Arck. d’ Elect. Med. 1912, Oct. 2S ; ^^Praci. 1913, i, 441 ; ^^Brit. Med. Jour.

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X-RAY TREATMENT

1913, i. S17 ; ^^Joiiv. Anier. Med. Assoc. 1912, 1770; Med. Jour,

1913, ii, 415, and Arch. Bonigen Ray, 1913. ii. 169 ; ^^Brit, Med. Jotiv. 1913.
ii, 529 ; Pvact. 1913. i, 53 ; -^Rif. Med. 1912, Oct. 19 (Brit. Med. Jour.
Epit. 1912, ii, 262) ; -^Lancet, 1913, i, 869 ; Baris. Hosp. Reps. vol.

xlvdii ; ^^Brit. Med. Jour. 1912, ii, 1367 ; ^^Arch. Rontgen Ray, 1912, ii, 23S ;
-^Ann. Surg. 1913, i, 100 ; -^Joiir..Laryn. Rhin. and Oiol. 1912, 507 ; Bosf.
Med. and Surg. Jour. 1913, i. 882 ; -Mancet, 1913, ii, 77 ; -^Surg. Gyn. and
Obst. 1913, 707: ^^Arch. d'Elect. Med. 1912, Nov. 25 {Brit. Med. Jour, epit.,
1913^ i* 35) i ^^Arc/i. d' Elect. Med. 1913, Mar. 25 {Brit. Med. Jour. epit.
19131 33S) ; ^^Brit. Med. Jour. 1913, i, 112 ; ^^Jour. Amer. Med. Assoc,

1913, i, 800, and Surg. Gyn. and Obst. 1913, i, 569.

X-RAY TREATMENT.

Uterine Myomata . — Great advances in the treatment of this condition
have been made of late. Gauss and Lembeke^ have made many
experiments, described in full in this paper, on the filtration of ,^r-rays ;
they have also experimented upon animals and plants with filtered
and unfiltered .r-rays. It is interesting to note that, in the case of
tadpoles, a definite dose of unfiltered rays which did not kill them,
proved deadly when filtered. They deduce from their experiments
the fact that it is necessary to use only hard rays to obtain good results
in penetration therapy. The principle of their method of treatment
is massive filtered doses of .r-rays from hard tubes from numerous
points of entry, and by this means getting cross-fire effects without
damage to the skin. Aluminium 3 mm. in thickness is used as the
filter. The tube is brought to a focus distance of 20 cm. from the skin.
Amenorrhoea is produced within six weeks with absolute uniformity,
and with no danger of burns or of late reaction. It is claimed that the
treatment can be carried out in five weeks, during which time a dosage
of 14S0 X is given, and the cures amount to 100 per cent. Grafenberg^
is sure that, in addition to the action upon the ovaries, the ,r-rays have
a specific action on the myoma itself. He considers that the best
results are obtained in cases of interstitial myomata in women past
fifty, in whom there are no strong indications for operation. Albers-
Schonberg® still prefers to treat these cases by smaller doses with the
tubes further off the skin, and does not attempt to cut short the duration
of time necessai'}- to bring about a cure. He uses two tubes working
at the same time, one below and the other above the patient. Each
series of irradiations is limited to four sittings of eight minutes each.
He now uses, instead of leather, a filter of aluminum 2 mm. in thickness.
Many other writers report great success with one or the other of these
two methods. For instance, de Boris'^ reports “ truly remarkable
results,"' and considers that, supposing radiotherapy fulfils its promises,
it ought to be used, since the risks of malignancy?- on the one hand and
operation mortality on the other, are about equal. He points out that
at any rate ;tr-ray treatment is almost absolutely safe, and that it avoids
the shock and other risks and drawbacks of an operation. Riinge,^
with an experience of 93 cases, advocates the method in carefully
selected cases, where the diagnosis is certain, and where there is no
suspicion of malignant disease or any other contraindication, The

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report of the discussion^ on this treatment at the InternationarCongress
indicates the views of various well-known workers, and should be read
by those interested.

Malignant Disease . — Pearce Gould, ^ in the Purvis Lectures on the
treatment of Inoperable Cancer, refers at length to the value of the
gamma radiations. These are given off by both an A^-ray tube and
* radium, and are those rays of the highest peneti'ating power ; and
whether produced by the one or the other are, for practical purposes
similar, according to Professor Rutherford, and capable of producing
similar effects. Radium gives off a number of rays, the most important
of which are the alpha, beta, and gamma : the first are entirely
absorbed by the thinnest form of filter, and in the various methods of
using radium are not employed therapeutically ; the beta rays are of
two sorts, those of very low penetrating capacity and those of higher ;
the former are again cut out by all the usual filters, the latter are of
some therapeutic value and will pass through thin metal filters. In
order to cut them out entirely, filters of lead of 3 mm. thickness are
used, and when placing these between the radium and the parts
exposed to treatment, only the high gamma rays pass through for
therapeutic purposes. In the treatment of deep-seated malignant
growths, when radium is applied for from many hours to even many
days continuously, this thick filtration is necessary for safety, and the
full use of the gamma radiation can be obtained. It is much the same
with .r-rays ; but the difficulty here is, firstly, to keep an .r-ray tube in
the very Ixard condition for the best production of the high penetrating
rays for the length of time necessary to make an effectual exposure ;
the second difficulty is in the application. Exactly in the same
way, filters must be used to cut out the softer and less penetrating
rays ; and with .r-rays, aluminium in various thicknesses has been found
the most practical. Used in thicknesses of from 3 to 5 mm. it is
possible, without damage to the skin, to give very large .r-ray dosage
to deep-seated growths ; but the tube and apparatus require careful
watching the whole time, thus differing from radium, which will go on
indefinitely without changing its radiation in any respect. Admitting
all this, there is no doubt but that some cases react favourably to .r-rays
and are a failure with radium, and vice versa. Why this should be so
is not known, but probably want of knowledge of the best method of
filtration, and the exact dosage required, is at the bottom of the failures
in either case. Different sites are easier of treatment by one or the
other, and without going into detail, it ma}^ be said that radium is
infinitely superior to v-rays for such conditions as Cancer of the Rectum,
Uterus, (Esophagus, and so on, whilst the prophylactic post-operative
treatment of a large area, such as is necessary, say, after the Removal
of a Breast and the clearing out of the axilla, is more favourable to
treatment by A'-rays. Sometimes a combination of the two will bring
about the- best result, such as for instance, the bur^ung of radium in
tubes in a growth, or in a mass of secondary glands, followed up
hammering away with frequent external applications from an activ^e

THERAPEUTICS

X-RAY TREATMENT

AT-ray tube. To quote the author : '‘Of the treatment of thesp
cases by the gamma radiations produced by an ;^-ray tube or radium, I
can speak with much satisfaction. These radiations can undoubtedly
inhibit cell growth, and they seem to have a special power over cancer
and sarcoma cells, and, more than this, they have the power of destroy-
ing malignant cells.” Testimony of this kind is of special value
when coming from such an acknowledged autliority.

Pfahler® has done a large amount of work in this direction, and writes
with authority and reserve. He reports his results in tv^elve cases of
Inoperable Breast Carcinoma, and gives each case fully. His results
in the directions of relief of pain, reduction in the size of the growth,
improvement in general health, and prolongation of life, are remark-
able. He lays stress upon the facts that no other method of treatment
has ever accomplished as much in the class of cases referred to in this
paper, and that the treatment should be carried out by one expert in
technique. Cumberbatch® reports a case of recurrent breast carcinoma
in which, after three months A^-ray treatment, numerous “melon-seed”
bodies scattered under the skin of the axilla and breast all disappeared.
A point about his result worth noting is that this was brought about
by quite small dosage, half to one S unfiltered, given once a month.
In contradistinction to this small-dose method, Mackee and Remer^®
advocate massive ;i'-ray doses in Cutaneous Epithelioma. A very thin
filter — a single layer of chamois leather — is employed, and a dose of
5 to 7 H of a B 6 ray administered. Many of the cases were cured with
a single dose; 'few had more than two. The authors aim at, and think
it beneficial to produce, a first degree of radio-dermatitis.

Closely allied to this subject is the ejfect of radio-active substances
and radiations upon normal and pathological tissues, in a discussion on
which Lazarus-Barlow^^ gives an account of his recent researches.
An interesting observation was that gall-stones from non-malignant
cases or cancer, excluding gall-bladder cancer, were not unusually free
from radio-active matter, whilst in no single instance had the gall-
stones from cancer of the gall-bladder failed to give evidence of a
relatively considerable amount. Hertwig also showed that while
full-grown and differentiated cells and tissues are comparatively little
affected, on the contrary, embryonic cells and others which in adults
lingered in an undifferentiated state, especially generative cells, young-
nerve cells, leucocytes, and tumour cells in a state of growth, were
especially sensitive to radio-active substances.

Myeloid Leiihannia. — Beclere^- irradiates the whole spleen through
aluminium filters, dividing the region into segments, so that each portion
of the spleen receives the same dose. A very short period of treatment,
bvo to three months, is sufficient in most cases to change the blood
condition completely, the most constant feature being the decrease of
the number of white corpuscles. The first phenomenon is the rapid
disappearance of the nucleated corpuscles, whilst the megaloblasts
and young cells disappear early. That complete cure does not take
place is shown by the fact that solitary myelocytes persist ; however,

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the author is aM'arc of cases still well, live or six ^^ears after v-ray
treatment. Petrone and T.ore"^'* record eight cases of Infantile Spleno-
megaly treated by A-rays. In four cases of pseudo-leukremic splenic
anaemia, the size of the spleen was reduced and leucocytes diminished.
In one similar case, and in a case of Leishmaniasis, whilst tlie size of
the spleen and the number of white corpuscles diminished, the
condition got worse, and death followed. There are certain dangers
in this treatment, and Cumberbatch^'^ calls attention to these in relating
a case of fatal leucopenia under his care. Full blood-counts are given,
and an attempt is made from these to indicate the danger signals.
[It is possible, however, that in this case the result was not directly
due-to the ;r-ra3'' treatment, but to some secondary septic infection,
inasmuch as the rapidly fatal stage was accompanied by an intlam-
matoiy condition of the throat. — C. T. H.].

Zimmern^’^ and Cottenot,^^' carried out a series of experiments on
patients suffering from Arterial Hypertension, and brought about a
reduction in almost all b}^ irradiation of the suprarenal region. The
technique is simple, the suprarenal capsule being always in a definitely
fixed position. ]\Iake the junction of the twelfth rib with the vertebral
column the centre of the irradiated area, and the suprarenal gland
will be reached. Protect the neighbouring organs with metal, leaving
an opening for the .r-ra^^s, and line the metal (lead for preference)
with a layer of felt next the skin. Hard rays should be used, 9 to lo
on the radiochromometer, and these should be filtered through i mm.
of aluminium. Irradiate both glands, one after the other, placing
the tube 15 to 20 cm. from the skin. The kidne^^ itself receives some
part of the irradiation, but this does not appear to be injurious. The
authors have analyzed the urine, and have found no trace of albuminuria
consecutive to the treatment. The dosage and number of exposures
can be regulated according to the results. In some cases there was a
lowering of 3 to 4 cm. Hg within forty-eight hours of the sitting, and
in several patients the results were maintained for months without
further irradiation.

Sciatica. — Louis Deiherm^" has treated cases since 1907 by Rontgen
therapy, and reports diminution of pain in nearly all. He urges that
this treatment should be used when the galvanic current has failed,
and especially in those cases in which the sciatica is due to some
compression of the root of the nerve. Small vu-ay doses are recom-
mended, in three separate instalments at intervals of , a week, the
total dose of each series to be 5 H of 6 Benoist hardness through \ mm.
of aluminium. The irradiation is to be directed on to the sacral
region and on the painful points in the course of the nerve.

Chronic Adenitis. — Max Roques^ is much impressed b^^ the results
of x-rsLY treatment in chronic glandular conditions due to micro-
organisms, the aesthetic result being superior to that obtained by
operation. He describes his technique. Ho employs one of three
methods of dosage, but usually administers a massive dose at one
sitting, followed bv a rest of from twenty to bventv-five days. Filfra-

THERAPEUTICS

X-RAY TREATMENT

tion by means of aiumininm should always be carried out. He obtains
good results, not only in superficial glandular enlargements, but also
in intrathoracic and intra-abdominal adenitis. [From our own
experience of the .v-ray treatment of masses of enlarged glands in the
neck, we are convinced that, combined with incision into breaking-
down foci, this treatment is preferable to excision. — C. T. H.]

In regard to Adenoids and Enlarged Tonsils, Stewart^® noticed that
ill those cases where there was also glandular enlargement, ;r-ray treat-
ment of the latter condition also brought about diminution in the size
of the tonsils. Following this observation, he has treated several cases
of enlarged tonsils with promising results, and in no case was there any
failure of reaction. Sometimes only two or three doses brought about
great relief to the symptoms.

Precocious x-ray Reactions have been noticed by Marques-*^ as attribu-
table to the action of .r-rays on the salivary glands. A few hours after
the exposure, a swelling sometimes appears at the irradiated region,
and even takes on a character suggestive of epidemic parotitis. In .
one case, after a feeble dose, the same evening the patient complained
of difficulty in mastication and deglutition ; the region was hot and
tender, and the next morning there was considerable tumefaction.
A second treatment, and a third, produced similar results. Pfahler®^
has seen the same phenomenon when treating a case of acne below
the ears. He suggests that it is in some way due to the electro-
static discharge which develops in the neighbourhood of the excited
;i'-ray tube when it is close to the tissues, and that it is probable that
other primary reactions which occur immediately after an x-vdcy
exposure are due to the same cause. If this is the case, they can be
prevented by the simple means of surrounding the area with earthed
metal. Regard, 22 however, believes that syphilis plays an important
role in the abnormal reactions vrhich occasionally follow radio-therapy
in spite of the most careful technique. He treated a case of bad
freckling of the hands with two very feeble applications of .v-rays ;
twent\-seven days later a severe radio-dermatitis developed, and left
in its train an ulcer the size of a two-franc piece on the back of each
hand. Syphilis was at the time energetically denied ; but later on the
patient, the ulcers having in the meantime healed, developed symptoms
of general paralysis, and shortly afterwards died, having also admitted
old syphilis.

Hernanian-Johnson^s has tried A'-ray treatment in two cases of
Chronic Progressive Diseases of the Spinal Cord, with promising results
as far as amelioration of the symptoms is concerned. He suggests
that two effects are produced : (i) A depression of the unhealthy

neuroglia cells ; {2) Stimulation of such neurones as are not too deeply
injured to respond. In both cases, on stopping irradiation, relapse
took place, followed by improvement on recommencing. Probably
it is not feasible to hope for more than to hold the degeneration in
check ; i.e., the patient must lead an “ ;r-ray life comparable with a
'' thyroid life " in cases of myxcedema. In Syringomyelia marked

X-RAV TREATMENT

medical annual

improvemetit may be looked for. Marques and Roger-^ irradiated
a case every other day with 3 to 4 H units, filtered ; at each sitting the
rays were directed upon a difterent part of the spine. After thirty-four
doses there was marked amelioration, with an increase of force and
voluntary motility. The troubles of sensibility were alleviated, and
the trophic changes disappeared.

Purpura. — -Triboulet, Weil, and ParaR^ rapidly cured a case of this
disease with four ;r-ray doses, two to the spleen, and one to each
femoral diaphysis. The patient suffered from purpuric patches,
vomiting, abdominal pain, and epistaxis. This is the first case of this
kind reported as being cured by A'-rays. Small doses are advised ;
in this case the maximum at each irradiation was 2 H, and it is suggested
that this mild dose stimulates the cells of the haematopoietic organs.

The .r-ray treatment of Hypertrichosis seems to be emerging from
the discredit into which it had fallen. Speder^® follows a technique
in which hard rays, 7 to 8 Benoist, are employed, filtered through
I mm. of aluminium. A maximum safe dose is given. The hair fell
out in from twelve to twenty-five days. Fi-om seven to nine weeks
after the first dose the hair begins to grow again, and a second similar
dose is given. In two or three months after this, a third, slightly
smaller, dose is given. Rarely is it necessary to do more than this.
The writer warns against applying this treatment to an undue develop-
ment of merely downy hair. It is not suited to such condition, and
should be reserved for large vigorous hairs, which have a much greater
radio-sensibility. He advocates the use of shaving or depilatory
pastes to attempt to change downy growth into true adult hair, and,
when this is accomplished, to cure the condition with .r-ray treatment.

Haldin Davis^^ calls attention to the fact that little has been published
in this country on the treatment of eczema by ;r-rays. He has treated
three cases of Eczema and Psoriasis of the Palm of a very chronic
character with great success. A lady of 68 had suffered for tliirty years
with fissured eczema of the palm of both hands. Two doses of approxi-
mately two-thirds of a pastille each resulted in disappearance of the
eczema and fissures and practical cure of the iiTitation. [These cases,
in their reaction to x-rays, are similar to those of chronic irritation
(itching) round the anus and vulva ; in these cases it is remarkable
how a tew small, uiifiltered ;r-rays doses will almost immediately cure
a patient completely whose sufferings for ^^ears have been almost
intolerable, and who has forgotten what a good night's rest means. —
C. T. H.]

References. — Med, Jour, 1913, ii, 922 ; “BerL klin. Week. 1912,
Apr. [Arch, Rontgen Ray, 1912, ii, 202) ; ^Arch, d’Elect. Med, 1913.. Apr. 10
and 25 [Brit, Med, Jour. Epit. 1913, h 311) ; '^Sem. MM, 1913, No. 40 [Brit,
Med, Jour, Epit. 1913, i. 216) ; HVien, med, Klin. 1912, No. 27" [Arch. Rontgen
Ray, 1913, i 36S) ; '^Trans. Radiol, Sect. I’jth Intr. Cong, of Med, ; '^Lancet,
1913, i, 215, and Brit. Med. Jour. 1913^ h. 90S; AV.Y. Med, Jour. 1913, i,
S53 ] ^Arclt. Rontgen Ray, 1913, ii. 7S ; Med. Jour. 1913, i, 634;

'^'^Brit. Med. Jour. 1913, ii, 460; ^-Ibia. Epit. 1912, ii, 269; '^^ibid. 32S ;
'^^Arch. Rontgen Ray, 1913, ii, 1S7 ; ^^Arch. d' Elect. Med. 1912, June [Arch
Rontgen Ray, 1913, i, 40S) ; ^^Brit. Med. Jour. 1913, ii, 142 ; '^'^Arch, Rontgen

XHERAi=>EUTICS

RADIUM

Ray, 1913, ii, 38; ^\iych, d' Elect. Med. 1912, July 25; (Brit. Med. Jour.
Epit. 1913, 189); Med. Jour. 1913, i, 1157; '^Arch. d* Elect. Mid.

1912, Aug. 23 {Brit. Med. Jour. Epit. 1913. ii. 30) ; -'Jour. Cutan. Dis. 1913*
June {Aixk. Rdt^tgcn Ray, 1913, ii, 163) ; ^“Arcli. d'Elect. Med. 1912, Sept. 25
[Brit. Med. Jour. Epit. 1913. i 259) ; Med. Jour. 1913. ii. 299 ; ^Kirch.

Rontgen Ray. 1913, ii, 162 ; -'^Bnll. de la Soc. de Fed. 1912, Nov. ; {Brit. Med.
four. Epit/igi3, i, 237) ; -^Brii. Med. Jour. Epit. 1912, ii, 342 ; "^"'Ihid. 1913,

i, 1053-

RADIUM AND ALLIED SUBSTANCES.

The most important publication this year was The Report of the Work
of The Radium Inslitufe, by Haward Pinch,^ and this should be
studied in detail for the facts given concerning the methods of using
the radium and the results obtained. Coveiing a period of nearly
seventeen months, it deals with the results of 578 cases. These were
not selected in any way, and equal prominence is given to cases in
which radium appeared to be useful and those in which it had l^een
useless or possibly harmful. In short, one object of the report is to
point out the conditions under which radium is of no therapeutic
value. Nothing could be better than the fair manner in which the
report deals with all classes of disease, and it is vei\v notable that the
word ‘‘cure” is not used in relation to malignant disease, although in
many of the cases it would seem justifiable to have said that cure had
resulted. The author of the report, however, contents himself with
the term “ apparent cure.” We would refer the reader to this
paper for the details of appliances, and the methods of application,
dosage, etc.

Rodent Ulcer is a disease most amenable to treatment by radium,
and this applies with added force to the ulcers of large area. Cases are
quoted and described in which other methods of treatment failed, and
in which radium produced most markedly good results. Whatever
may be said as to the method of treatment to be applied to small
rodent ulcers, there seems to be no doubt that nothing is so effectual
as radium in the large and inoperable ones.

In Carcinomata of the Rectum and of the Breast, promising results
are noted. In Carcinoma of the Uterus, inoperable cases may be made
operable, haemorrhage is arrested, discharge diminished, ulceration
healed, and pain greatly relieved. No other known method of treat-
ment will bring about some of the results obtained. In Epitheliomata,
very different results are obtained in those affecting the glabrous skin
from those involving mucous surfaces. In the former the action of
radium is most favourable, but in epitheliomata of the tongue, buccal,
gingival, and pharyngeal mucous membranes the effect is almost
uniformly disappointing. Conditions more amenable to the action
of radium are epitheliomata of the vaginal and uterine mucosa.

Sarcomata are best treated by the insertion into their centre of tubes
containing as much as 50 to 100 mgrams of radium, and these, screened
with from 0*5 to i mm. of silver, can be left in position for from twenty
to thirty hours ; this fi'equently proves most effective ; the tumour
shrinks in size, and becomes replaced by dense fibrous tissue.

RADiUJVl

MEDICAL ANNUAL

A noteworthy feature of the report is the appendix, the report of
the Cheniico-physical Laboratory by W. L. S. Alton, which deals fully
with the various applicators, the measurement of activity, the screens,
the secondary rays, etc., and is full of important and valuable hints
as to the rationale of the treatment in addition to the actual technique.

Robert Knox^ publishes a thoughtful paper on the results of his
experience at the Cancer Hospital. He thinks the claim that radium
possesses a selective action on cancer cells is a bad description
of its effects. It acts on all living cells according to the resistance of
the particular cell in question ; young and actively growing cells are
more readily influenced than mature cells, and the cells of a new growth,
approximating in structure and resisting power to these, are so much
the more readily subject to the action of radium. The factors influenc-
ing the result of treatment are : (i) The type of growth and the condition
of the patient; (2) The situation, size, etc., of the tumour; (3) The
quantity of radium used; { 4 ) The filtration employed; (5) The dura-
tion of the exposure. He concludes that radium is a useful adjunct
to the treatment of all cases, first as a prophylactic after operation,
and, failing operation, the next best method we possess. It must,
however, be stated that ;r-rays are in selected cases quite as useful.
In inoperable cases, radium may help to render the case operable ;
and, failing that, it is undoubtedly useful as a palliative measure.

Dawson Turner® has treated 41 patients during the year 1912, and
finds radium most beneficial in Naevus and Rodent Ulcer. One port-
wine stain was cured. In 12 cases of malignant disease his results
are not encouraging, although one case of recurrent epithelioma of the
ala nasi was completely successful, and in three other cases there was
improvement.

In a paper on Inoperable Cancer treated by radium, Warden* details
some of his experiences, and regrets that so many cases are allowed to
reach such an advanced stage before being sent for treatment. “ When
we cause an epithelioma that has been known to exist for a year or more
to disappear entirely, and when a few months later the patient dies
from a metastatic growTh, we have a just claim that the action of
radium on cancer is demonstrated, and that the secondary growth,
had the radium been used earlier, might never have occurred.” He
gives details of several striking cases, some apparently hopeless, and
in every case marked relief to the sufferings of the patient was
effected.

M‘ Kendrick and Teacher^ discuss a case of Cancer of the Throat,
in which the action of radium was followed for a time by such marked
improvement in the local condition that the possibility of recovery did
not seem remote, when unfortunately, septic infection and haemorrhage
caused death. A post-mortem examination showed that whilst all the
main pharyngeal growth had been destroyed, and healing of the mucous
membrane had taken place over the whole area, a small portion of the
tumour had reasserted itself in the soft palate, and malignant tissue
w^as found lower down in the neck. In this instructive case, large

RADIUM

THERAPEUTICS 53

amounts of radium were inserted for as long as forty-eight hours into
operation wounds.

In Cancer of the Stomach, Julien® has had success in two cases. In
one, in which there was extreme cachexia and a tumour the size of an
orange in the pyloric region, after laparotomy a tube containing i cgram
of pure radium sulphate placed in a Nelaton's soft rubber catheter was
iniroduced and left in position for fifty hours upon the tumour, two
other tubes of i cgram each being placed upon the abdomen. In ten
days the tumour had disappeared to palpation. In a second similar
case two similar tubes were introduced and applied for seventy -five
hours, whilst six applicators of various strengths were applied outside.
A month later the external treatment was repeated. In a few months
the tumour had gone, after a third external dosage, and the patient
resumed a normal life.

A case of Inoperable Cancer of the Cervix Uteri is interesting from
the fact that definite proof of the cure is complete. Chei'on and
Rubens-Duval" record this case. The tumour, squamous epithelioma
by microscopic examination, w’as treated by the implantation of
20 cgrams of radium in several tubes for forty-eight hours. Later,
7 cgrams were similarly used for twent^T-'four hours. The patient
died from cerebral haemorrhage two and a half years later, and no
trace of malignant growth was found at the autops}’-. Numerous
sections of the cervix and right broad ligament were examined micro-
scopically, and not a single cancer ceil was found. Aikens and Harrison®
also report three similar cases of very advanced and inoperable malig-
nant disease, and in each, in addition to marked amelioration of
symptoms, there vras definite retrogression of the disease and
disappearance of ulceration.

Into a recurrent small-celled Lymphosarcoma of the neck, Dawson
Turner® introduced a glass tube containing 20 mgrams of the bromide,
and left it in position for thirteen days, at the same time applying
40 mgrams externally for four hours daily over different areas. The
total internal dose amounted to 6240 mgram hours, the external to
S680 mgram hours. After a further operation, a tube was introduced
into the cavity left, the dose being 3360 mgram hours. No trace of
the disease could be found three months later, and after a year had
elapsed, the patient remained quite well.

Degrais’® records three cases of Bhinophyma successfully treated
by radium. Two were of the glandular and one of the elephantiac
variety. In all, the abnonnal secretion and congestive phenomena
disappeared little by little, and the hypertrophied tissues sank down.
Full details of the technique are given.

The action of radium on B. leprae is described by de Verteuil,i^
who applied 80 mgrams of the bromide to leprotic nodules for one hour.
The nodules were reduced in size, but marked changes also took place
in the appearance of the bacilli present in them. For thirteen days
no change was found, but after this, increasing granular degeneration
was marked, until after four weeks no bacillus could be seen. The

RADIUM

MEDICAL ANNUAL

suggestion is that as there M*as no apparent action before fourteen days,
the bactericidal effect was not direct, but exercised through some
chemical process on the tissues. If it were possible to radiate all the
tissues of the body with radium rays it might be a cure for leprosy.
Possibly the drinking of large quantities of radium water might be
effective.

In four cases of Exophthalmic Goitre, Dawson Turner^^ reports that
there was a distinct amelioration of the symptoms. The author claims
that the two advantages of radium over x-rays in this disease are :
(I) That a definite dose can be administered and repeated ; (2) That
radium can be applied without noise or excitement whilst the patient
is in bed. It is probable that the effect of radium on the thyroid gland
is to diminish vascularity and leucocytosis, and to cause an overgrowth
of connecti\'e tissue.

References. — Med. Jour. 1913. i, 149; -Ibid. iiq6 ; ^Ihid. 606;
^Pract. 1913. ii, 19 ; ^Glasg. Med. Jour. 1912, ii, 241 ; ^Arcli. d' Elect. MM.
igi2, Dec. 10 {Bnt, Med. Jour. Epit. 1913. h 4S) ; 'Lancet, 1912, ii, 1385 ;
^Med. Press and Circ. 1912, ii, 567 ; ^Arch. Ronigen Ray, 1913. i, 418 ; ^^Arch.
d'Elect. MM. 1912, iMay 25 {Brit. Med. Jour. Epit. 1913, ii, 60) ; ^KArcIi.
Rontgen Ray, 1913, if 53 ; ^^Lancet, 1913, ii, 924.

ELECTROTHERAPEUTICS.

Finsen Light. — Sequeira^ gives a full account of the results of this
method of treatment as carried out at the London tiospital from 1900
to 1913. The highly satisfactory character of the results in Lupus is
shown by the statistics : 99 cases have been free from recurrence for
ten years and upwards, 277 for from five to ten years, and 168 for from
three to five years. These results speak for themselves. 117 patients
have been cured, but there have been small recuiTences. 161 cases
have derived benefit, but are of such a character that they have never
been, and probably never will be, quite free from the disease. 31
patients are classed as hopeless, the disease being not materially influ-
enced. 127 cases have for one reason or another not persevered. The
author points out that the whole of the benefits cannot be ascribed to
Finsen light, as no otlier means of help — operation, etc. — have been
neglected, but admitting this, the bare record of cases and results
is proof positive of the powerful action of the Finsen treatment,
Sequeira has no doubt but that to the devotion and care of the
sisters and nurses a large amount of the success is due, and this
means that to get the best effect of the treatment it must be
carried out in a systematic manner, with the accompaniment of the
best skill and technique.

The Galvanic Current. — Cheriton^ strongly advises this in the treat-
ment of Chilblains. He has obtained uniformly good results in both
relief and the prevention of recurrence. The technique is to place the
hands and feet in two baths of saline water into which the galvanic
current is directed at whatever intensity it can be supported, covering
the more irritating spots with collodion in the first place. Treat for
twenty minutes daily for as long as is necessary, passing the current in

THERAPEUTICS

IONIC MEDICATION

one direction for the first ten minutes and reversing it for the second.
Itching will diminish or disappear from the first.

Incmidescent Light . — -Laquerriere and Loubier^ recommend this for
obstinate cases of Atonic Wounds. Daily exposures of from twenty to
thirty" minutes to a 32-candle-power lamp placed in a reflector, healed
wounds which had failed to respond to other methods of treatment.
As instances of the deeper action of ‘‘ luminotherapy and the trophic
character of the radiations, the authors cite two cases of osseous
rarefaction, in an index finger and in an astragalus, both of which
improved considerably under this simple treatment. If white light
causes irritation, they advise that the glass shall be tinted blue.

Ultva-violet Radiation has bactericidal properties, and can be utilized
lor the sterilization of drinking water, etc. A system has been intro-
duced into some French and Indian to\vns. Recklinghausen'^ describes
the technique adopted, which is to place the quartz-mercury-vapour
lamp in close proximity to the passing water ; and for domestic use
(hospital or private), 130 gallons can be sterilized per hour.

High Frequency Currents. — Somerville'" speaks highly of the beneficial
results obtained in Trigeminal Neuralgia, and insists on the necessity
of skilled supervision, and of perseverance. He quotes a striking case
of long duration and much severity, in which cure was rapid and
apparently permanent. In addition, he has treated many cases of
neuralgia of all degrees of se-v'erity, in which relief and often complete
cure has resulted.

Referexces. — Hancet, 1913, i, 1655 ; Kirch. d'Elect. Med. 1913, Feb. 25
(Brit. Med. Jour. Epit, 1913, ii, 125) ; ^Ibid. 1912, Rov. 25 (Brit. Med. Jour,
Epit. 1913, i, 19) ; ^Brit. Med. Jour. 1913, i, 464 ; ^Ibid. 1912, ii, I70(>.

IONIC MEDICATION.

Ionic medication is defined by Dr. Lewis Jones as a method of
treatment in which electric currents are used for their power of setting
the constituents of a saline solution in orderly motion in a definite
direction. This definition is sufficiently broad to embrace all the
ionic actions used in medicine, for the tissues of the human body differ
in no respect from ordinary saline solutions in their conductivity of
electricity.

All substances fall naturalh" under three headings as regards electrical
conductivity: (a) Conductors, (h) Non-conductors, (c) FJectrolytes. To
the third class belong most of the drugs used in medicine, and a member
of this class of substances has the property of allowing an electric
current to pass through aqueous solutions, but only at the expense
of its own dissociation, or electrolysis as it is called. Physicists have
now clearly shown that when a body of this class, for example sodium
chloride, is dissolved in water, many of its molecules are at once dissoci-
ated and split up, free atoms of sodium and free atoms of chlorine
making their appearance in the solution. The free sodium atom
carries a positive charge of electricity upon it, while the free chlorine
atom carries a negative charge. These free charged atoms are called
ions (i.e., travellers), and it is to the presence of ions that the solutjoii

IONIC IVIEDICATION

5<3

MEDICAL ANNUAL

of an electrolyte owes its conductivity, for pure water is a very bad
conductor indeed.

If into this solution of sodium chloride two electrodes, attached
respectively to the positive and negative poles of a battery, be intro-
duced, the positiveh?- charged sodium ions which lie near the negative
electrode will be at once attracted by it, and will give up to it their
positive charge ; while the negatively-charged chlorine ions will be
repelled by the negative electrode and driven off into the liquid towards
the positive electrode. At the positive electrode, the negativeh" charged
chlorine ions will be attracted and give up their negative charge, while

the positively charged sodium ions will be repelled and driven off
through the liquid towards the negative electrode. The net result
will be a steady stream of ions across the liquid, a transference of
eiectricit}' from one electrode to the other, and the appearance at
either electrode of free uncharged atoms or groups of atoms, which
must be clearly distinguished from the charged atoms or ions. The
current wdll flow from the positive to the negative electrode in the
liquid ; and it will be seen that the positive sodium ions move in the
direction of the current stream, and are therefore called kathions,
because they travel down stream, while the negati^’ely charged chlorine
ions move against the current, and are therefore called anions, because
they travel up or against the stream,

THERAPEUTICS

rONIC MEDICATION

As the human tissues act towards an electric current in a manner
similar to the saline solution, a convenient method of introducing
drugs into the body at once presents itself. For instance, it is desired
to introduce iodine into the tissues at a certain point. If a folded
piece of lint soaked in iodide of potassium be placed over the part, and
a plate attached to the negative pole of a battery be applied, while
a similar piece of lint moistened with saline solution and connected
to the positive pole of the battery is placed upon some other part of
the body, the iodine ion from the pad attached to the negative pole
will be driven into the tissues under the lint, while sodium, potassium,
and other kathions will pass from the skin into the iodide pad. The
diagram {Fig. i) will make this clear. Similar actions will at the
same time be going on at the positive pole ; but in this case the posi-
tive pole has simply acted as an entrance for the current, and we are
not concerned with what may be taking place there. Iodine introduced
in this way does not enter the blood-stream, as it must do when given
by the mouth, but is directly introduced into tlie cells and lymph-
spaces, and reaches the cell in a far more concentrated form than can
be achieved by any other method of medication. Fig. 2 represents
in a similar way the introduction of zinc ions under the positive
plate.

The dose of an ion introduced by any current is capable of very
accurate measurement, and the following table shows the pole at which
various ions must be introduced, and the dose of each which will be
administered, if one milliampere of current be allowed to run for one
minute.

Anions, which must be applied at the negative pole : —

Bromine . . -049 mgram | NO^ . . *04 mgram

Chlorine .. *022 „ ! .. *016

CO2 . . *019 „ I SalicyHc Acid *685

Hydroxyl . . -oi „ | So^ ^ . . -029

Iodine . . -078 „ I

Kathions, which must be introduced at the positive pole : —

Ammonium . . *003 mgram Potassium . . -024 mgram

Calcium . . *012 ,, Quinine . . -234

Cocaine . . *iS Silver . . -oO

Gold . . *04 ,, Sodium . . *014 ,,

Hydrogen . . '0006 „ Strychnine . . *207

Lithium , . *004 „ Sulphur . . -oi

Magnesium . , -007 „ Zinc . . . . *02

Mercury . , *062

That drugs can be introduced deeply into the tissues by this method
of electric propulsion there is no doubt. Finzi, experimenting with,
ferrocyanide ions on the knee of a monkey, and using a current of 10
milliamperes for thirty minutes, was able subsequently to demonstrate
the presence of the drug in the cartilage of the joint. Gautier also
succeeded in driving copper ions through the uterine wall of a rabbit
I mm. thick in ten minutes with 20 milliamperes of current.

fONIC WIEDICATION

MEDICAL ANNUAL

Practical Points in the Application of the Method,

1. The pads which are interposed between the pole plates of the
battery and the patient’s skin must be of considerable thickness (ten
to twenty la^^ers of lint or several thicknesses of Gamgee tissue). If
this point is not attended to, the alkali or acid produced where the
current passes from the metal plate to the pad, or vice versa, may
penetrate through the pad and damage the skin.

2. The solution used to moisten the pad which is to supply the ions
to be introduced into the tissues must obviously be a solution which
contains the desired drug in the form of ions. In other words, the
solution must contain an electrolyte. A solution of carbolic acid or
sugar would be useless to moisten the pads with, because the molecules
of neither are dissociated to form ions.

3. The pads must be well wet with the solution, and must be applied
in thorough contact with the skin and held in position firmly with a
bandage or rubber bands,

4. The pads must be washed free of solution after each treatment,
and soaked again in a fresh solution of the drug for the next application.
There are two reasons for this procedure : the solution becomes
weakened in ions by use, and the acids and alkalies already mentioned
accumulate and may become dangerously concentrated on the pad
after a few applications.

5. Care must be taken that the current is running in the correct
direction to introduce the particular ion which is in use. If a kathion
is being used, it must be placed under the positive pole ; if an anion, it
must be placed under the negative.

6. A milliamp^remeter must be used to measure the strength and
variation of the current, and some form of rheostat must be employed
in the circuit, in order that the current strength may be slowly and
evenl}" brought up to the desired intensitt’ without unpleasantness
to the patient.

7. The strength of the solutions used for the pads need not be very
great, i per cent being suitable in some cases ; 2 per cent is a useful
strength for iodide of potash and sulphate of zinc; the latter can,
however, be used in a strength of 10 per cent if a deeply caustic action
is desired. A 2 per cent solution of salicylate of soda is a convenient
strength when the salicylate ion is to be introduced.

8. The strength of the current which can be employed will depend
largely upon the size of the pads applied to the skin ; a strength of
3 milliampares per square centimetre of surface being usually borne
quite comfortably. If strong currents are to be used, large pads are an
essential.

9. The source of electric supply may be: (i) Some form of dry cell.
Such cells are handy, but seldom can be relied upon for more than a
year. A battery of at least t\velve cells, giving 24 ^'olts, will be needed.
(2) Wet Leclanche cells, such as are used for electric bells. These
ser^^'e well for use at home, but are not portable. {3)- One of the many
instruments at present manufactured, in which a current is drawn

THERAPEUTICS

IONIC MEDICATION

from the windings of a motor worked from the lighting mains, of which
the multostat and the pantostat are examples. (4) Direct from the
lighting main, with a suitable resistance on circuit to control the strength
of the current. If the main current is used, care must be taken that
the patient is thoroughly insulated, as otherv^dse dangerous shocks may
result.

Ionic medication yields satisfactory results in the following diseases :
Lupus, 1 rodent ulcer, ^ simple chronic-ulcer, diphtheritic ulcera-

tion, ®,", ophthalmia neonatorum, s trachoma,®, 1°, ulceration of the
nose, 2 ozaena,^^ antral suppuration, rectal ulceration, anal fissure,
piles,^" colitis,^® enlarged prostate,^' gonorrhoea®, vaginitis,®®
endometritis,®^,®®, boils, carbuncles and sycosis,®® ringworm,®'^ warts,®®
corns,®® alopecia,®" gout, 25^203031^ neuralgia,®®,®®, sciatica,®'^,®®,
rheumatism, acute and subacute,®®,®’, rheumatoid arthritis,®® gonor-
rhoeal arthritis,®®, acne,^® psoriasis,^i branchial fistula.-^®

References. — ^Liverp. Med.-Chir. Jour. 1911, Jan; -Lancet, 1905, Oct.
2S ; Barts. Hasp. Jottv. 1912, Aug. ; Trans. Austral. Med. Con^. vol. iii,
1908, Oct. ; ^Proc. Roy. Soc. Med. (EIeciro 4 hevap. Sect.) vol. ii, 140 ; ®Lewis
Jones, Ionic Medication , 43 ; '^Brist. Med.-Chir. Joiiv. 1909, 135 ; ^Brit.
Med. Jour. 190S, Nov. 7 ; ^Jour. Amer. Med. Assoc. 1S95, May 4 ; ^^Brit.
Med. Jour, igog, g'/ 6 ; ncet, igoS, ii, 73S; i®Lewis Jones, Ionic Medica-
tion, 59 ; "^^Proc. Roy. Soc. Med. (Surg. Sect) i. 176 ; '^■‘^Trans. Austral. Med.
Congr. 190S, 18S ; ^°Proc. Roy. Soc. Med. [Electro-therap. Sect.) ii, 135 ; ^Mancet,
1905, Nov. 4; ^'^Brit. Med. Jour. 1911, Oct. 14; ^^Ibid. 1908, Aug. 15;
"^^ArcJi. d' Elect. Mid. 1909; ^^Proc. Roy. Soc. Med. {Electro-therap, Sect.) ii,
123 ; ®^ 76 zW. vol. iii. ; -^Bvit. Med. Jour. 1909, Jan. 9 ; ®®W. J. Morton,
Cataphoresis, New York, 189S ; -^Glasg. Med. Jour. 1912, Feb. ; ®®Le^^is
Jones, Ionic Medication^ 83; 84 ; Ibid. 85; Arch. d'Elect.

Med. 1S99, June ; -^Pract. 1S9S, Sept. ; Lancet, 1909, i. 756 ; ^“^Arch.
d'Electr. Med. 1910, 531 ; ^-Ibid. 1904, July 2^ ; ^^Brit. Med. Jour. 1908,
Apr. 4 ; ^^Arck. d*Elect. Mid. 1909, Oct. 10 ; ^Mbid. 1911, May 10 ; ^^Arch.
des Labor, des Hdpitaux d’Alger. 1906, June; Arch. d’Elect. Mid. igio.
May 25 ; ®®Lewis Jones, Ionic Medication, 119 ; ^^BuU. Offic, de la Soc. Franc.
Elect. 1905, June; ^^Sem. Mid. 1909, Nov. 17; •^'^Ann. d'Electro-Biol. 1909,
S46 ; ^^Revue Internationale d' Eiecfro-fherap . v, 350.

THORIUIVI

HEDICAI. ANNUAL

THORIUM.

PROFESSOR CARL VON NOORDEN,

Consuiting^ Physician in Franhfort-on-Main ;

AND

PROFESSOR WILHELM FALTA,

Assistant in the first Medical Clinic in 1 7cnna.

At present we know of three groups of radio-active elements : the
uranium group, to which radium belongs, and the actinium and thorium
groups. Thorium oxide was discovered in 1828 by Berzelius, who was
afterwards able to classify metallic thorium among the alkaline earths.
Its atomic weight is 232*5, and the minerals which yield most are
uraninite, containing 4 to ii per cent thorium and 65 to 74 per cent
uranium, and thorianite, containing 65 to 74 per cent uranium and
4 to 1 1 per cent thorium. These minerals, rich in thorium, are princi-
pally derived from Ceylon. Of greater importance, however, is mon-
acite gravel, from which mesothorium is derived. In this mineral,
which is rich in cerium salts, mesothorium is mixed with thorium oxide,
and also always with uranium salts. Commercially, it is derived from
monacite as a b^^-product in the manufacture of the Auerlicht incan-
descent mantle. Mesothorium, and its near relative, radiothorium, were
discovered in 1907 by Hahn, who recognized their high radio-activity.

Like the members of the other radio-active groups, the elements of
the thorium family possess the faculty of becoming converted into
new elements with lower atomic w^eights by gi\ing oS “ rays.*'
As in the case of uranium and radium, so also with the members of
the thorium series, three types of “ rays have hitherto been found.
These types, which are quite different from each other, are : (i)
The alpha " rays, helium atoms, which carry a positive electrical
charge ; (2) The ** beta ” ra3^s, which are electrons, or the minutest of
units of negative electricity ; (3) The “ gamma " rays, which are not
material particles at all ; they are regarded as similar to light,
electro-magnetic oscillations in ether. They are not known to possess
any electrical charge.

Of the greatest importance in relation to their practical value, is the
rapidity with which this dissolution takes place. As a measure of this
the '' half- value time has been chosen ; i.e., the time which a certain
quantity of radio-active substance takes to convert half of itself into
the next member of the series, bj’ sending forth the characteristic
radiations. These periods vaiy enormously, as the following table
shows : —

THERAPEUTICS

THORIUM

The Thorium Group.

“ Half-value-time”

Element

Rays

1,000,000,000 years

Thorium

5*5

Mesothorium I

—

6*2 hours

Mesothorium II |

0 , y

20 3^ears

Radiothoriuni i

3*65 days

Thorium-^r i

a ,0

53 seconds

Thorium emanation I

614

Thorium A |

10 ‘6 hours

Thorium B

60 ’5 minutes

Thorium C

a, /3

Thorium D

/3, r

Since the activity of radio-active substances is proportional to the
number of rays given off in a unit of time, thorium, with its infinitely
long period of dissolution, is of no importance as a radio-active body.
Practical interest begins with mesothorium formed from thorium after
millions of years.

The mesothorium on the mai-ket is not a pure substance. It con-
tains radium in the proportion of 3 to i ; so far it has not been possible
to separate the radium from the mesothorium. In addition to the
pure mesothorium I (in the chemical sense of the word), all the lower
members of the thorium series (mesothorium II, radiothorium, etc.)
are present, as well as a considerable proportion of inactive substance.
One hundred mgrams of commercial mesothorium contain *25 mgram
of mesothorium, with the radiant energy of 75 mgrams of radium
bromide ; 25 mgrams of radium (in terms of the bromide), wdth the
radiant energy of 25 mgrams of radium bromide ; and 74-75 mgrams
of inactive substance.

As mesothorium wastes infinitely faster than radium (in the ratio
of 5*5 to 1800 years), so the energy which it emits in a unit of
time is much greater than that of radium, at all events with the fresh
substance ; i mgram of fresh commercial mesothorium has a radiant
energy equivalent to that of 300 mgrams of radium. The value of
mesothorium is not according to its weight, but is expressed thus :
100 mgrams of mesothorium preparation have the energy value of x
mgrams of radium bromide. To find this total involves a complicated
explanation of physical technique, which cannot be entered into here.
The total must be knowm in order to calculate exactly the amount of
the preparation and the time of application w-hich are necessary. For
example, if one reads that to obtain good results in the treatment of a
rapidly-growing uterine cancer 20,000 mgram-hours distributed over
twenty days are necessary, and the mesothorium preparation in one’s
possession is equal in value to 100 mgrams of radium bromide, the
preparation must be left in contact with the diseased tissues for quite
200 hours, or an average of 10 hours daily.

As a consequence of the peculiar distribution of the radio-active

THORIUM

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MEDICAL ANNUAL

substances in commercial niesothorium, it reaches its maximum of
radio-activity about three 3'ears after its initial preparation ; the
activity" is then gradually’ dispersed, and reaches its original grade once
more at about the tenth ^^ear ; after another ten \'ears it possesses onl}^
half its original energ^v this time there is not much left of the
thorium series of radio-active substances, and such radio-activity as it
still possesses is due to the radium included in it. This ma^^ be regarded
as constant in relation to the span of human life, for its half- value-time
is 1800 3^ears.

It is the mesothorium mixture that is used, a substance which as a
whole is not soluble. For special purposes the preparation is enclosed
within capsules of celluloid, or other material penetrable b^^ the
radiations, and deposited in the bod}" cavities (vagina, uterus, bowel,
oesophagus, etc.), or in tumours. The duration and number of
applications are regulated b}" the special circumstances of the case.
As a rule it is to act upon the depths of the tissues ; if we appl}"
it, we have often to enclose it within thin sheets of lead or
aluminium, to filter off the injurious alpha-rays and prevent the
burns which have become well knowm and dreaded in connection
with A'-ra}^ work. This metal filter transmits part of the beta-ra^’S
and the whole of the gamma-ra^’s. Or the mesothorium may
be mixed with indifferent substances, such as tonschlamm, fango,
or organic material, sewn up in small bags and applied to the appro-
priate part. For special purposes various well-defined methods have
already been evolved, and it is important to refer to the collected works
on this subject, in order to secure a maximum of beneficial activit}!-
with a minimum of risk. In the journal Strahlen Therapie (vol. iii,
H. 1) a number of contributions will be found dealing with these
important questions, and at the same time with the modern view of the
more theoretical considerations (contributions b}' A. Sticker, E. Engel-
hom, P. Kroemer, Ph. Jung, P. Haendh", C. J. Gauss).

The second bod}^ in the thorium series which is of importance to the
practitioner is thorium-r, Avhich is isolated by a complicated process
from radiothorium (mainly at the Auer ^Vorks in Berlin). Thorium-v
is slightly soluble in water, forming a colourless solution. Its radio-
activity, in contrast to that of mesothorium, is very transitory, as a
glance at the preceding table will show. Next to it comes a gaseous
substance, thorium emanation, which has onh" a veiy brief life, a fact
which serves to distinguish it from radium emanation, the duration of
the existence of which happens to be about equal to that of thorium-A'.
The brief life of thorium emanation naturalty makes its use therapeu-
ticalh’ in an isolated condition impossible ; but, on the other hand,
the rapidit}" of its transition promises for it great advantages o\"er
radium emanation. The latter can only become fixed in the bod}’ with
difficulty, since the absorptive capacity of the blood and tissues is
slight so far as tliis gas is concerned ; the consequence being that the
greater part of it is rapidl}* re-exhaled, and only a part of the total
radiant energy which was taken into the body comes into action. With

THERAPEUTICS

THORIUW

thorium emanation it is otherwise. The portion of life of thorium
emanation is so brief, that only a very small fraction of it can be
exhaled : by far the greater part goes into the system itself, in the
form of those substances wliich follow it, thorium A-D, substances
which are ph^’sically solid, and exercise a powerful and enduring
effect by virtue of the electrical explosions which arise during the
transformation from one element to the next one. The excretion of
the thorium elements takes place gradually {25 per cent of the mass
injected is excreted within four days).

So far as its application to therapeutics is concerned, the radio-
active energy of thorium-.jt' proceeds from substances whose mass is too
s nail to be weighed ; for this reason the mass of thorium-A' to be
employed is calculated in terms, not of weight but of energy-content,
and it is ordered, for example, as 50 to 100 electrostatic units of tho-
rium-A for daily use (50,000 to 100,000 “ mache units '' in the older
nomenclature). Solutions of thorium-A' are prescribed sometimes for
oral administration, at others for intravenous or intramuscular injec-
tion. A lively controvers}^ has sprung up as to which is the best form
of administration. Our own extensive observations show that there
is a real advantage to be derived from injection of the thorium-A' in the
neighbourhood of the tissues to be acted upon (e.g. in the vicinity of a
diseased joint) ; the much more important general effects of the sub-
stance are in no way better secured by intravenous than by oral
administration, but the dose needed to produce these by the oral
method is somewhat higher.

The chemical effects of the thorium element are not different from
those of radium, and it is indeed from a study of radium that most of
our knowledge of the chemical effects of radio-active bodies has been
gained. Its biological action also harmonizes closely with that of
radium ; yet a certain difference is observable in its intensity, owing
to the variabiiit)^ of the content of alpha-, beta-, and gamma-rays in
radium and thorium preparations.

The principal of these biological effects may be brieih^ reviewed here :

1. The soluble ferments of the body (diastase, pepsin, trypsin, etc.)
are said by some waiters to be influenced by the alpha-rays of thorium
preparations ; some say they are inhibited, others that they are stimu-
lated. What seems to be the fact, however, is this (W. Falta) : that
material wiiich has been previously or simultaneously subjected to the
chemical effect of the rays, is more readily and quickly acted on by
ferments ; larger doses of the rays prolong the process.

2. The endocellular ferments of the body, and particularly those
that are autolytic, are always stimulated, never inhibited, by radiation.

3. Lower plant growths (bacteria, etc.) are inhibited, and even killed,
by large doses of the rays (from mesothorium, or by introduction into
solutions of thoriuin-A). So far, however, it has not proved possible
to apply this fact to therapeutics.

4. The development of plants and of animal ova is stimulated by
small doses, but definitely inhibited by large ones.

THORIUM

MEDICAL ANNUAL

5. In the local action of radio-active substances, and particularly
of mesothorium, on animal tissues, it is possible — speaking generally —
to perceive a stimulation of growth (even in tumours) under the influence
of small doses ; large doses, after a certain latent period, induce necrotic
changes, to which some tissues — that of neoplasms in particular — are
especially liable.

6 . The general effects on the animal organism (with special relation
to thorium-.ir) are as follow : —

(a). Sthmdation of the respiratory metaholism (increase of the caloric-
exchange). The rise in the minimal metabolism during rest may
amount to 20 per cent and more. Plescli's statement, that the respira-
tovy quotient shows a definite increase, lacks confirmation (Bernstein).
Such a stimulation of oxidation could until now only be effected by
administration of thyroid substance. Thorium-.r, which may be given
without anxiety in medium doses over a long period, is therefore a
suitable adjuvant in the treatment of obesity. On the other hand,
experience shows that the use of radio-active substances is absolutely
contraindicated wherever it produces an unwelcome rise in the
energy exchange, e.g. in Fever, Graves’ Disease, and Diabetes Mellitus.
In the latter, radium and thorium-^r produce a definite increase in
the glycosuria.

(&). Increase in the Protein Exchange. — This effect is quite insig-
nificant.

(c). Ptirin Metabolism. — A limited increase in the exci*etion of uric
acid which is found under the influence of radium, takes place just
as well with thorium-;tr. Its destructive influence on tissues rich
in nuclei should be considered here, in the face of its very definite
action on gouty processes ; however {vide infra), the increase in the out-
put of uric acid appears but small and transient. It is therefore reason-
able to suppose that the action of thorium-.^ lies not merely in a mobi-
lizing influence on the sources of uric acid in the body (the nuclear sub-'
stance of the tissues, and especially of the leucocytes), and on uric acid
deposits (joints, tophi), but also in a promotion of the destruction of uric
acid itself. Experiments in \dtro (W. Falta) confirm this hypothesis.

{d). The Red Corpuscles. — Small doses of radium (e.g. a single injection
of yV mgram radium bromide), also small and medium doses of thorium-
50 100 electrostatic units daily) lead to hyperglobulism,

apparently by direct stimulation of blood-production. Large doses
have a precisely opposite influence, apparently by direct destruction
of the red corpuscles. With corpuscles of normal resistance, this
deleterious effect begins to be exercised at a daily dose, often repeated,
of about 300 electrostatic units. If the resistance is subnormal, how-
ever, much smaller doses are dangerous to the red corpuscles ; and
under these circumstances a hemorrhagic diathesis ma}^ be induced.

{e). Leucocytes. — Under very small doses (e.g. the usual small doses
employed in oral and inhalatory administration of radium emanation)
a hyperleucocytosis develops. Thorium-.v, however, in doses above 50
electrostatic units daily, msiy lead to a definite diminution in all the wdiite

THERAPEUTICS

THORIUM

corpuscles of the blood. After a three weeks’ course of about 100 units
daily, the leucocytes in normal persons are nearly always reduced
to 2000 or 3000 per c.mm. ; with still larger doses they may
disappear from the blood almost entirely. In animal experiments ol
this latter type there are extreme degeneration of the spleen pulp and
atrophy of the lymphoid tissue ; beside this, the chromaffin tissues
degenerate, a change to which the sharp fall in blood-pressiu'e which
occurs is apparently due,

(/). Coagulation of the Blood . — The coagulability falls in direct pro-
portion to the measure of the radio-active substances used, particularly
with thorium-.v. This tallies with the clinical observation, that in
haemorrhages of e\"er\’ kind the utmost foresight in the prescription of
thorium-A' is imperative.

(g). The nervous system is notably stimulated by small and moderate
doses of thorium-A'. For elderly persons, and those manifesting various
kinds of Nervous Exhaustion, it is a valuable tonic. The daily amount
must not exceed 40 to 50 electrostatic units. The explanation is not
yet forthcoming. We ought, however, to remark that the highly radio-
active baths of Gastein and Kreuznach have been proved by the
experience of many decades to be powerfully stimulant to exhausted
nerves. Not long ago Dr. Heiner, of Joachimsthal, wTote describing
similar results.

(//). The reproductive glands are very sensitive to radio-active sub-
stances. Their local action, like that of the Rontgen rays, may induce
sterilit}’. The usual small doses of radium emanation are indifferent.
The somewhat larger content of radium-energy, which is usual at
Joachimsthal, as well as oral application of 30 to 40 electrostatic
units of thorium-AT, increase Potency (Dr. Heiner’s and our own
personal observations). Really large doses have an opposite effect.

Therapeutic Application, — With these general biological observations
the indications for therapeutic applications are in agreement. Hero
we can only give a brief re\Tew, in addition to some critical remarks
based on our own very extensive observations.

Tumours of various types and sites, benign as well as malignant,
can be treated ehectively only by local application (radium or meso-
thorium). To secure results in rapidly-growing tumours of moderate
size, at least 12,000 to 15,000 mgram-hours are necessary. Up till
now the best results have been realized in Uterine Cancer, and many
experienced gyncccologists now prefer radiation to total extirpation.
The question is still undecided ; a few more years are needed in order
to reach definite conclusions about it.

Sterilization of Women, — In the treatment of Uterine Myoma and
other diseases. In young women, the results for the most part seem to
be temporary only ; after one to three months ovulation occurs again,
if the treatment has not been repeated. In older women, however, a
single brief course of treatment, sometimes within a few days, gives a
definite start to the menopause. This refers only to_the local action of

THORIUM

MEDICAL ANNUAL

radium or mesothorium. Hitherto the gynaecologists prefer the
Rontgen rays for these purposes.

Treatment of Obesity. — Allusion is made above to the adjuvant
eifect of thorium-;!? given internally. Specialh?, von Noorden speaks
of its beneficial effect in connection with the Homburg cure, in respect
both of weight reduction and of improvement in bodily freshness and
capacity for work.

Chronic Rheumatic Affections of the Joints, Muscles, and Nerves. —
Local applications (of small bags containing Joachimsthal pitchblende
refuse, mud containing mesothorium, etc.) have to be considered, as well
as baths and oral administration of radium emanations (Joachimsthal,
Kreuznach, Mtinster-a-St., Gastein), and above all, oral administration
of thorium-.v (50 to 80 electrostatic units daily). Almost always this
leads at first to perceptible increase in the symptoms (swelling and
pain), but later, beneficial effects are seen. It is not yet known
satisfactoril}" by what means the radio-active substances act upon
the rheumatic process.

We have in the meantime only to acknowledge the facts. To be
frank, it is not possible to reckon a priori wuth confidence on good
results in rheumatic cases.

Gout. — The inhalations of weak radium emanations, originally
recommended b^’' His, have proved to be quite inadequate. The
treatment with radium emanations, with the patient shut up in a
tightly closed room, has been proved to be almost superfluous, since in
thorium-.v we have found a much more controllable and convenient
radio-active substance. ^ We give it to gouty subjects, sometimes intra-
venousl5^ sometimes by mouth ; we prefer the latter, as a rule. The
daily dose varies between 50 and 100 electrostatic units, the duration
of a course of treatment being from two to four weeks. Luring the
treatment, careful observations of the number of leucocytes and of the
excretion of uric acid must be kept. A sharp increase in the former at
the outset of the treatment is to be desired ; but after four or five days
the total should return to an amount corresponding to the dietetic
intake. Gouty persons, undergoing treatment with thorium-.r, should
always be in the hands of an expert. The}’ seem to be more sensitive
than other patients to the radiations. We see, moreover, that treat-
ment with thorium-,r, carelessl}- superintended and lacking expert
control, may, in the gout}’, lead to anaemia, leucopenia, and cardiac
weakness. If carefully conducted, however, it does not involve the
least risk, and it has an obvious effect on the attacks and on tophi.
Treatment by oral administration can be carried out two or three
times in a year.

Loss of Sexual Power . — {Vide supra.)

Anaemia. — ^The hopes entertained of the value of thorium-.r in the
treatment of pernicious anaemia have not been realized. It is true
that the erythroplastic system (bone-marrow) can be, so to speak,
whipped up by this means, and that under these conditions the number
of red corpuscles rises quickh’ ; but the gratification is short-lived ;

THERAPEUTICS

THORIUM

and it appears to us — contrar}’ to the enthusiastic and precipitate
descriptions given by a number of other writers — that in this disease
treatment with thorium*A^ has no future. Moreover, this is readily
understood, since in pernicious anaemia one has always to deal with a
haemolytic t\'pe of anaemia : the point of attack of the morbid process
lies in the corpuscles themselves ; the bone-marrow is over-stimulated
in response to them, and thorium-;tr merely adds another stimulus of
brief duration thereto. On the other hand, our experience with
anaemia due to deficient marrow acthdty is favourable, and especially
in chlorosis ; even in severe and unusualty obstinate cases, which
ha^^e proved resistant to iron and arsenic, we have seen splendid
results.

Leukaemia. — Here we are scarcely concerned with radium ; the results
obtained by thorium-A' are such as are achieved by the usual application
of the ,v-rays. In essentials we are deahng with a similar therapeutic
factor {similar rays). If good results are to be obtained, the dosage
must exceed 100 electrostatic units per day. Such doses should, how-
ever, be given for t^vo or three days only ; then a pause should follow,
during which the number of leucocytes and red blood-corpuscles should
be carefully counted, and the resistance of the latter estimated. Further
treatment is regulated by what is found. Careful observation and
personal experience prove that for leukaemia, thorium-;if is not merely
as good as Rontgen therapy, but that it is moreover susceptible of much
more accurate gradation. The danger of skin bums, which it is true
can be prevented in modern ;r-ray treatment, are of course completely
avoided. It is too soon to say that the prognosis of leukaemia is defi-
nitely improved by the introduction of the thorium treatment. At all
events, the treatment of this disease with thorium-,r promises more for
the future than that of pernicious anaemia by the same means.

Thus far, treatment with preparations of the thorium group has by
no means proved a panacea for the general practitioner’s use, but
remains stiU in the hands of those who have acquired special skill and
experience in its employment. This is well. It is an unsafe form of
energy to play with. One mgram of radium gives off in an hour -iiS
calories, answering to the heat value of *5 kilo of first-class coal.
With thorium-.v the total energy?” is infinitely greater. The sum of a
million electrostatic units, which could never be used practically, is
contained within a mass of thorium-A' considerably below the smallest
measurable weight. Compared with the fatal dose of thorium-Ar, an
equal weight of our strongest aU^aloidal poison would appear as an
innocent substance. It is electrical poiver with which we are working.
In contradistinction to all other forms of electro-therapy, we possess
in the radio-active substances means of carrying electrical energy into
the depths of the body, and there subjecting the juices, protoplasm,
and nuclei of the cells to an immediate bombardment by explosions of
electrical atoms. We may, therefore, designate this internal treat-
ment with radio-active substances internal electrotherapy.

TUBERCULIN THERAPY

MEDICAL ANNUAL

T U B E R C U L I N THE R A P Y .

r.v

LAWRASON BROWN, A.B., M.D., New York ;

AND

EDW. N, PACKARD, JuN., Pii.B , M.D., New York.

Tuberculin has, during the past year, continued to excite great
interest and much discussion in all gatheiings of students of pulmonary
tuberculosis. This has been particularly so in Great Britain, where
many of the most important contributions were made public.^

Theory of Action , — The explanation of the action of tuberculin still
rests upon hypothetical grounds. Tuberculin is not a toxin, and
forms no antitoxin. It was formerly held to excite, when injected into
healthy animals, neither sensitiveness (anaphylaxis) nor the formation
of antibodies. It has been clearly shown, however, that u'hen tlic
second dose has been injected into the blood-stream or into the
cranium of a sensitized animal,^ anaphylactic symptoms do supervene,
though often larger quantities are required than in serum anaphylaxis.
Experimental passive anaphylaxis^ occurs regularly, and hyper-
sensitiveness can be transmitted from mother to offspring, which does
not take place through the milk.-^

It has been held by most workers that tuberculin treatment is a
process of active immunization. The tuberculous infection stimulates
the formation of lytic substances, which in turn attack the tuberculous
poison in the cells or circulating in the body, and by a process of
parenteral digestion, split it up.® The therapeutic injections of tuber-
culin increase these lysins. They may set free certain antigens (partial) ,
which in turn call into existence more lytic substances.

Beraneck® and Sahli,’ on the other hand, hold that tuberculin
treatment is not a process of active immunization, but rather an
immunisatory healing action. Two processes are concerned in recovery
from tuberculosis — one lytic, the other sclerogenic and absorptive.
The former is connected with the “ protecting cells (phagocytes,
hepatic cells, etc.), and the latter with the “reparative cells” (con-
nective-tissue cells). Tuberculin stimulates or educates these cellular
activities (properties). Now the value of any specific treatment
depends upon (i) the stimulating or reaction -producing power of the
treatment used, and (2) upon the capability of the cells to respond to
the stimulation by the formation of lytic substances, capabilities which
may vary with the condition of the patient and during the course of
the disease, and with the tuberculin. Reactive processes occur in all
tuberculin treatment (even when reactions are apparently absent),

THERAPEUTICS

TUBERCULIN THERAPY

and consist in the stimulation of the formative inflammatory anti-
bodies and the specific tuberculin amboceptor. This amboceptor
splits tuberculin into harmful (fever-producing) and later into harm-
less products (antithermic effect). Tuberculin treatment is not an
active immunization (which never occurs in tuberculosis), but only a
curative treatment, and the rules of active immunization do not hold.
The aim should be to determine the optimum dose, not to reach large
closes, which may be dangerous. Repetition of the optimum dose
encourages disintoxication '' of the patient. Fever is not a contra-
indication, and intrafocal injections in surgical tuberculosis are to be
recommended. Exception may be taken to some of these statements,
but their work is full of suggestions.

Excellent papers along these lines were contributed by Sims Wood-
head® and by E. R. Baldwin.®

Many attempts to produce an active immunization in animals to
tubercle bacilli by the use of tuberculin have failed ; in fact, such
sensitized animals, Krause® and Austrian^® found, might or might not
succumb more rapidly than normal controls to an injection with
virulent tubercle bacilli.

In an interesting article, Alleii^^ attempts to analyze the failure of
tuberculin to produce better results. He states what has long been
known, that no antibodies so far discovered seem to have any impor-
tance in the production of immunity against the tubercle bacillus.
A thoroughly efficient vaccine should be prepared from autogenous,
fully virulent, freshly isolated cultures that have been subjected to as
little heat or antiseptics as possible, or it should be polyvalent. He
warns against its use in unsuitable cases, or by untrained men.

In an editorial in the Journal of the American Medical Association^'^
the historical side of the use of living tubercle bacilli in immunization
was discussed, and it was shown that as early as 1S91 Trudeau had
used slightly virulent cultures for this purpose with partial success.
It has long been known that in healthy cattle, onl)- living tubercle
bacilli can bring about any degree of immunity. The effect of such a
vaccine upon tuberculous animals seems to hold the primary lesion in
check for a time, and when this ceases to be active, the seat of the
secondary infections may show signs of disease. S. A, Petroff, F. H.
Heise, and Lawrason Brown^® attempted to immunize guinea-pigs by
the method of Barber and Webb (injecting at weekly intervals approxi-
matety i, 2, 3, 5, 10, etc., tubercle bacilli up to 1000). The treated
animals outlived the controls, but eventually some died from tuber-
culosis, and all became tuberculous.

The success of vaccination against small-pox suggested the idea that
a non-virulent tubercle bacillus might produce some immunizing or
curative effects. Accordingly, when F. F. Friedmann^^ announced
that he had obtained astonishing results by the injection of a living
“ cold-blooded'’ tubercle bacillus (turtle), the possibility that he had
acquired a potent vaccine occurred to many, although A. Moeller^®
had previously tried and abandoned such treatment. After a brief,

TUBERCULIN THERAPY

MEDICAL ANNUAL

but w-ell conducted, advertising campaign in the American newspapers,
Friedmann came to Ne\v York. Every opportunity was given him
to prove liis claims, but his inconsistencies and his lack of scientific
spirit quickly turned from him man}^ who were at first inclined to
believe him. The results obtained in bone and joint cases \vere in
some instances striking, but in many no improvement was noted.
The immediate results among the 'patients with pulmonary tuberculosis
were not so favourable as among the “ control cases (Barnes).^® At
first, the treatment was looked upon as harmless, but owing to the
violent reactions that may occur, it is quite possible that the death of
the patient may be hastened. jMannheimer,^’ who is rather favourable
to the Friedmann treatment, could see no benefit in his eighteen patients.
A Canadian commission came to the same conclusion, and while no
published statement has come to the authors’ attention, they under-
stand that in two New York hospitals, the .treated patients did no
better than the untreated. The United States Government was
unable to satisfy itself that Friedmann’s claims had been sub-
stantiated.^^ Friedmann is said to have carried at least ^20,000 back
to Germany, and many look upon the whole thing as a gigantic fraud
perpetrated by a money-grabbing news syndicate. The Friedmann
Institute in New York City was closed by the Board of Health.

M. Rabinowitsch,^^ who speaks in an offhand manner of his ability
to obtain cultures of tubercle bacilli from the patients’ blood, claims
to have destroyed at will the virulence of tubercle bacilli, and with them
to have immunized guinea-pigs against virulent tubercle bacilli. This
work lacks verification.

In 1901 Piorkowski^o prepared pure cultures for Friedmann from
two turtles which had become spontaneously tuberculous. Of a large
number of turtles wdiich he inoculated wdth this tubercle bacillus,”
only two became affected in a similar manner. Piorkowski now uses
two preparations : one a suspension of living turtle tubercle bacilli,
and the other an old tuberculin made from its cultures. He gives
three doses of the suspension intravenously, and then 100, 500, and
1000 mgrams of the tuberculin, at rather long intervals. He has had
no abscesses develop, and the symptoms soon abate. He mentions
Meyer, Bandelier, Klemperer, and Karfunkle, of Berlin, as using the
preparation.

A few still use INIarmorek’s serum, and report a certain percentage of
favourable results. No scientific evidence exists for such treatment.-^

Tuberculin in Diagnosis . — It is of considerable interest to note that
tuberculin is being used less and less for diagnosis. The ophthalmic
reaction is occasionally dangerous. The cutaneous reaction in adults
is of little or no value when positive. The Ellerman-Erlandsen
modification of the cutaneous test has not been sufficiently controlled,
but is apparently little used.-- Many observers who warmly advocate
tuberculin therapeutically, just as warmly oppose it in the form of the
subcutaneous test, which the}' declare is dangerous. Salili* states
that it should never be used, while Camac Wilkinson-^ urges its use

THERAPEUTICS

TUBERCULIN THERAPY

whenever tubercle bacilli are not present in the sputum. Gelien and
Hamman^-^ conclude from a study of the subsequent history of 1000
patients who received the tuberculin tests, that they are of value
only in reference to the condition of the patients at the time they are
gi^’en ; that a reaction to a conjunctival test with a i per cent solution
of tuberculin, in the absence of other clinical evidence, cannot- be used
as evidence of the presence of tuberculous disease. As regards
prognosis, more of those (in the various stages) who reacted to a i per
cent conjunctival test have died than of those who did not react ; while
in patients dying of tuberculosis, the length of life following the
administration of the tuberculin tests is approximately the same in
those who react as in those who do not.

It is impossible in many cases to diagnose or to exclude secondary
infections in pulmonary tuberculosis, hlaii}’- have used secondary
vaccines, and, like Ilundle,^^ obtained an occasional excellent result.
Hudson,-® however, obtained good results in 20 to 30 per cent only of
400 cases at Davos. Radcliffe,^’ in the Parkes Weber prize essay for
1912, states that in the majority of cases of advanced pulmonary
tuberculosis, the tubercle bacillus is the sole infecting agent, that
vaccines made from the organisms obtained in some cases b}" careful
washing may prove of some value, and that serum therapy against
secondary infection is not likely to be of service.

New Ttiberculin , — ^The search for an improved tuberculin still
continues. Tebesapin (W. Zeuner) has changed its name to
“molliment.” Moeller and Wolfits used this heated emulsion (70 to
72° C. for one hour) of tubercle bacilli already subjected for seven days
to the action of sodium oleate, on animals, but were unable to find it
any better than other tuberculins.

Lyons^® has precipitated O.T. with absolute alcohol, and calls it T.F.
It is only a weak tuberculin.

Dixon’s tuberculin (a physiological salt solution of soluble matter
in tubercle bacilli which might have been extracted with ether and
ground up) was used b}’ Francine and Hartz®® with good results.

Tubolytin (Siebert and Roemer)®^ is a watery extract of tubercle
bacilli, which keeps well and is free from extraneous substances. It
differs apparently little from v. Ruck’s watery extract, and is much
weaker than O.T.

Tuberculin Rosenbach (O.T. weakened b}’ the growth upon it of
Tvichophyfoh lioloscvicum album) has found advocates in Drowatsky
and E. Rosenberg. Elsaesser^^ reports good results when injected
near skin and lar^mgeal lesions ; and after trying intrabronchial
injections, now obtains good results by intrapulmonic injections of
o-i to i-o c.c. Fortunately the tuberculin is weak. Lesser and
Koegal,®-^ in a lengthy study, concluded from their work on animals
that it was a weak tuberculin ; from their work on men, • that it could
be used in diagnosis (1000 mgrams final dose), could cause some
unpleasant symptoms, and might be used in treatment without danger
if the dosage is small enough.

TUBERCULIN THERAPY

MEDICAL ANNUAL

Stimulated apparently by the work of Friedmann, v. Ruck®® has
re\'ie\ved.the literature on the relative value of living and dead tubercle
bacilli and of their endotoxins in solution in active immunization
against tuberculosis. Many -wdll recall his watery extract and his
claim that it was similar to v. Behring’s tulase. Ruck’s new extrac-
tion differs but little from his former, but now he states that all the
specific antibodies are present in the blood-serum of every case after
a “ single full dose,” that under proper conditions of complement and
antigens a “maximum bacteriolytic” power is manifested, that the
immunized animals resist, while the controls always succumb to, a
virulent infection, and that in over 150 patients a “single full dose”
was invariably followed by what may be termed a “ clinical cure.”
Julian,®® who has worked with v. Ruck, obtains similar clinical results.
Cummings,®" who attempted to repeat v. Ruck’s experiments, may
have used too large doses of \'irulent tubercle bacilli ; but in any case
he obtained no evidence of immunit}^ as his treated guinea-pigs all
died about as quickly as the controls. This work should be fully
confirmed before being accepted, and animal experimentation should
precede the treatment of patients.

Poduschka®® reports good results following themse of Weleminsky’s®®
“ tuberculo-mucin.” This is a tuberculin made from a growth of
tubercle bacilli so changed that its metabolic activity gives rise to a
coagulable protein and mucin. Korb^® has obtained good results with
“ sanokatzin tuberculin,” which contains o*oi gram calciumglycero-
lactophosphate and 0*005 gram tuberculin in i c.c. of physiological
salt solution. Romanelli-^^ reports favourably on the immunizing
properties of tuberculous sputum dried by heating. Perlich^® believes
“ tuberculosan-Burow ” to be of value in bovine tuberculosis.
Kirchenstein^® has published a long article on the studies she has
made in Spengler’s laboratory on the lytic value of “ I.K.” Meyer and
Schmitz believe that tuberculin unites with some part of the
erythrocyte, and by it is carried into the focus.

Several years ago Vaughan-^® suggested that the tubercle bacillus
could be split up into two parts, a poisonous substance and a sensi-
tizing residue. B. White,**® who has carried on some of this work,
states that it seems possible that the sensitizing property of this residue
may be due to the presence of a small amount of whole protein.

The Variety of TubeYculin to be Used . — Each form of tuberculin has
its advocates. Some dwell much upon the “ exotoxin ” and “ endo-
toxin,” but no one has so far shown that an “exotoxin” exists.
O.T. contains many substances beside tuberculin, and for this reason
many advocate albumose-free (x\.F.) tuberculin. Brown*" was the
lirst to combine an extract of the tubercle bacillus with the pulverized
germ under the name of B.F. Co. Others have also used similar
combinations hlff -Eisner). Sutherland**® uses a polyvalent tuber-
culin, consisting of O.T. (human) *025 c.c., O.T. (bovine) *025 c.c.,
human vacuum tuberculin *025 c.c., bovine vacuum tuberculin *025 c.c.,
human T.R., *05 c.c., bovine T.R. *05 c.c., human B.E. *033 c.c.,

THERAPEUTICS

TUBERCULIN THERAPY

bovine B.E. *033 c.c., potyvalent bouillon emulsion *034 c.c., P.T.O.
•35 c.c. and T.O.A. *35 c.c.

Dosage , — There is no conformity in the dosage of tuberculin. The
majority are inclined to favour a veiy small first dose and a carefully
regulated increase. Little use has been made of the opsonic index to
regulate the dose, though Colebroold® writes of it very favourably.
The use of the maximum non-reacting dose (method of White) has
been used by Cashman^*^ in surgical tuberculosis with good results.
White's method consists in determining the tuberculin-sensitiveness
of the patient by a modified cutaneous test, which does not allow for
any variation in the absorptive power of different skins. Brownes
suggests the use of the intradermic test to determine the sensitiveness
in regard to the first dose. Sahli's"^ and Brown's^’ scale of increase
may be found in their writings, while Barcroft®® has simplified
Wilkinson's schema. Sahli’ seeks the optimum dose, which may be
small, and repeats it. So far as we can tell to-day, it seems wisest
to repeat any dose until it ceases to benefit the patient, and then to
increase slowly to large doses, which experience has shown are usually
necessary to form antibodies in sufficient quantities to be demonstrable.
White 51 pleads for a standardization of tuberculin, so that dosage can
be more exact ; but granting that such can be established, of what
value would it be when the susceptibility of different patients varies
as one to ten thousand ?

It is now generally accepted that the subcutaneous method is alone
accurate. Mackenzie “ 5 states that he has given 4000 mgrams of O.T.
by mouth to a tuberculous patient without reaction. With T.R.
this is not so, but a much larger dose is required. B. Moeller showed
some time ago that oral administration was very uncertain. Wood-
head® states that a pint of O.T. given orally produces no effect.
Petruschky^® urges the rubbing in of his “tuberculin mitigatum “ in
the form of a liniment.

A. Michailowskaja^" uses twenty .solutions of tuberculin, the weakest
containing in i c.c. -000,000,000,000,001 gram. He injects twice
a week, and once a week tests the cutaneous reaction. If at the end
of twenty-four houis the papule is as large as the previous weaker
injection produced, the dose is repeated ; if smaller, the dose is
increased. He claims good results.

B}' the daily injection of to gr. of strychnine hydrochloride
subcutaneously for four or five days before giving tuberculin,
Whelan^s found that no bad results folloAved, and large doses could be
more easily arrived at. This is of interest on account of the fact that
tuberculin is said to lower the blood-pressure, and strychnine may
counteract that tendenc3\ Raw^^ states that all pent-up pus should
be freed before tubeiculin is given, as otherwise general tuberculous
infection might occur. He still believes that bovine tuberculin should
be used for patients infected with the human tubercle bacillus and
luunan tuberculin for bovine infection. Honl®^ combines nuclein with
tuberculin, because it increases the number of leucocytes temporarily.

TUBERCULIN THERAPY

MEDICAL ANNUAL

The use of tuberculin in febrile patients has apparently given some
excellent results. Very small doses of B.E. or S.B.E. are most videly
used. Samson believes it can reduce fever, with or without producing
any discoverable change in the focus.

Dangers of Tiiberculin, — Fowler*^'^ believes that tuberculin is ahvavs
dangerous, and specially so when fever is present or tuberculin reactions
occur. It will be recalled that Virchow earl}^ attacked tuberculin, and
said it caused a scattering ” of the tubercle bacilli, which statement
he modified later. More recently, L. Rabinowitsch^’^ reports finding
tubercle bacilli in the blood of tuberculous animals after the tuberculin
test, when previous examination had been negative. Bacmeister^^^ ex-
amined the blood of fifteen patients during the height of the tuberculin
reaction, and obtained positive results b\^ animal inoculation in four.

Tuberculin Dispensaries . — ^The most remarkable thing in connection
with tuberculin treatment during the last few years has been the
striking growth of the '' tuberculin dispensary,” so strongly urged by
Wilkinson.-*'^ “ In less than t\vo years more than forty centres have
been established.” In his article on the r^le of tuberculin dispensaries,
Wilkinson includes a polemic against Sir William Osier, and says later :
" I am just now completing observations extending over three years,
and I do not hesitate to say that, although we have been working
under most exacting conditions, strictly confining ourselves to the use
of tuberculin without having recourse to drugs or improved diet, or
improvement in the life-surroundings of the individual, I think we can
produce evidence which demonstrates pretty clearly that relapses are
less frequent and slower to appear than in cases treated by the simple
sanatorium methods.” He states further that this experiment in
London, covering a period of three ^-ears and open to investigation by
all, now approaches its termination, and concludes that to all unbiassed
observers it will prove the main points upon which he has advocated
this treatment. Parsons writes enthusiastically of this method, and
Bennett‘S® less so.

Results . — ^The results of tuberculin treatment have been anah^zed
by Bardswell®' and Shaw.®® The former concludes that from a clinical
point of view tuberculin was a negligible factor, and in no wise influenced
either the immediate or the ultimate prospect of the patients to whom
it was given. Three months later he stated that patients who took
tuberculin w'ere more likely to lose their bacilli (a long-known fact).
Riessmann®® noted the same result. At the suggestion of Batty Shaw,
Riggs'® treated ten cases, but too frequent and probably too large
doses of tuberculin, render the experiment of little value. Some months
later, Watkins,'^ also working with Shaw, treated eleven patients,
three febrile, six intermittently febrile, and two afebrile, with tuber-
culin, without apparent benefit. Sha\v®® has critically reviewed the
results of tuberculin treatment, and has come to the conclusion that
they were not controlled and are therefore of little value. Mackenzie,®^
who gives no figures, believes that selection of cases may account
for the good results, which are not “ brilliant, certainly not convincing.”

THERAPEUTICS

TUBERCULIN THERAPY

Elderton and Ferry in a study of the patients treated with and
without tuberculin at the Adirondack Cottage Sanatorium, and, the
Ayrshire and Bridge of Weir Sanatoriums, state that there is no evidence
from the mortality shown in the data’ to prove that tuberculin as
compared with ordinary sanatorium treatment, appreciably lengthens
the life of the consumptive.

Effect of Titberculni on the Blood. — ^iMiller, Lupton, and Brown find
that tuberculin in any dose may markedly increase the number of
leucocytes. A slight leukopenia ma^^ occur shortly after injection.
Following a positive tuberculin test, there was always . an essential
increase in the number of leucocytes. No appreciable change in blood-
pressiue was noted in tuberculin-treated cases, even after the largest
doses {800 to 1000 mgrams). From a study of Arneth’s neutrophilic
blood picture in fifty cases, they conclude that the nuclear picture is of
no value in determining the dose of tuberculin for therapeutic purposes,
and that, following the subcutaneous tuberculin test, the picture is not
changed until the stage of reaction occurs, when there may be a slight
shifting to the left. Durel,’-^ however, believes the Arneth index of
value as a guide in tuberculin dosage. Black"® finds an increased
leucocytosis following tuberculin treatment, and that the polymorpho-
niiclears show an increased power of phagocytosis to the tubercle
bacillus ; also that Arneth’s picture shifts to the right after tuberculin
treatment, which is at variance with the observations of Miller, Lupton,
Brown,'® and M. Solis Cohen and Strickler.’^® Duke’^ finds a. great
increase in the platelet ‘count in animals following the injection of
tuberculin.

Among the notable contributions to the tuberculin literature during
the year are fifteen theses by Sahli. ’ Some of his beliefs are as follows :
All tuberculins are essentially identical. There is no proof of the
existence of a tubercle exotoxin. The best tuberculins are those freest
from adventitious albumins. The degree of the dilution is of
importance. Diagnostic injections (subcutaneous) and ob\ious clinical
reactions, are dangerous. Tuberculin treatment is chielb/ valuable in
incipient cases, though it may produce a symptomatic effect in
advanced cases. The famil}’’ physician should know how to administer
tuberculin. One should not seek the point of tolerance, but the optimum
close. As a rule, acute cases cannot be treated. Well-diluted tuberculin
treatment constitutes a real and great therapeutic progress.

B. jNIoeller,'® in a conservative review of the subject of tuberculin,
sums up as follows : A combination of sanatorium and tuberculin
treatment is the best ; it can be used in early and carefully selected
ambulant cases ; tuberculin treatment of to-day is characterized by
very small doses, gradually increased without reaction to larger doses ;
the final result depends less upon the form of tuberculin than upon its
method of administration ; the treatment must be individualized,
and not given by rule of thumb ; it should be given subcutaneously
and in repeated courses, not only by sanatorium physicians but by
private practitionei's.

TUBERCULIN THERAPY

MEDICAL ANNUAL

During the past year new editions of two oi the best books on tuber-
culin have appeared. “ Tuberculin Treatment/' by Riviere and Morland,
and " Tuberculin Treatment," by Sahli. The former is the best book
for a beginner, and the latter is full of suggestion for the more advanced
observer. Tuberculin in Diagnosis and Treatment," b^^ Hamman
and Wolman, is an excellent handbook, and covers the literature
completely.

Summary. — During the past year little advance has been made in
the scientihc use of tuberculin. It still rests upon an empirical basis.
As a rule, onl^r its advocates write about it. What has always puzzled
the authors is the fact that, use tuberculin how they will, they can
never bring- about such happy results as many of its ardent supporters
claim. It seems that so far no statistical proof has been adduced to
show that tuberculin is much superior to other forms of treatment
in many patients ; but in a few the results are so striking that those
who obtain them are over-enthusiastic.

References. — ^Tmns. NatL Assoc. Prev. Consump. 1913; ^E. R. Bald-
win, Jotir. Med. Research, 1910, xvii, 189; ®A. K. Krause, Ibid, 1911, xix,
361 ; and unpublished communication ; ^C. R. Austrian, Johns Hop.

Hosp. Bull. 1913, 141 ; ®Thiele and Embleton, Zeit. f. Immun.-Forsch. 1913,
xvi, 178 ; ^Trans. Natl. Assoc. Prev. Consump. 1913, 49 ; "^Ibid. 57 ; ^Jbid,
25 ; ^Johns Hop. Hosp. Bull. 1913, 220 ; ^^Jbid. ii ; ^^Jour. Vaccine Therapy.
1913, 201 ; ^^Jour. Amer. Med. Assoc., 1913, ii, 753 ; ^^Unpublished com-
munication ; ^*Berl. klin. Woch. 1912, 2214, 2241, and 1913, 2070 ; ^^Tuber-
culosis, 1913, 465; '^^Jour. Amer. Med. Assoc. 1913, ii, 1066; ^"^Med. Rec.
1913, 1030; "^^Trans. Natl. Assoc. Prev. Tub. 1913, ix, 29; ^^Berl. klin.
Woch. 1913, 1 14 ; Jotir. Vaccine Ther. 1913, 137 ; ^^Deuf. med. Woch. 1913,
780 ; ^'^Rev. Int. Centralhl. f. Tub.-Forsch. 1913, vii, 672 ; ^^Lancet, 1912, ii,
688; ^^Jottr. Vaccine Therap. 1913, 119, and Pract. 1913, i, 159; ^^Jokns
Hop. Hosp. Bull. 1913, 180; “^Liverp. Med.-Chir. Jour. 1913, 132;
^^Lancet, 1912, ii, 114S, and 1913, i, 158S ; f. Tuberk. 1913, xxi, 2-j ;

med. Woch. 1913, 149; -^Lancet, 1912, ii, 1582; ^^Joitr. Amer. Med.
Assoc. 1913, ii, 717 ; ^^Tuberculosis, 1913, xii, 507 ; med. Woch. 1913,

1241; 119S ; '^^Beitr. z. klin. d. Tuberk. 1913, xxvii, 103; '^'^Med,

Rec. 1913, i, 507; ^Hhid. 1059; ^’’Jouv. Amer. Med. Assoc. 1913, i, 25;

klin. Woch. 1913, No. 6; ^^Berl. klin. Woch. 1912, 1320; ^^Zeit. f.
Tuberk. 1912, xix, No. 6 ; ^^Rev. Jnt. Central, f. Tub.-Forsch. 1913, vii, 6S1 ;
^^Ibid. 674 ; ^^Zeit. f. Tuberk. 1913, xx. No. G ; ^^Deuf. med. Woch., 1912,
1963 ; ^^Travs. Natl. Assoc. Prev. Tub. 1907, 237 ; '^^Ibid. 1913, 315 ; ‘^"Tuber-
culosis (Ed. Klebs), 547; ‘^^Trans. Nail. Assoc. Prev. Consump. 1913, 76;
•^^Pracf. 1913, 13S ; ^^Amer. Jour. Med. Sci. 1913, i, 213 ; ^^Arch. Int. Med.
1910, vi, 449 ; ^^Amer. Jour. Med. Sci. 1912, ii, 234 ; ’^^Brit. Jour. Tub. 1912,
vi, 203 ; ^Mrans. Natl. Assoc. Prev. Consump, 1913, 70; ^^Lancet, 1913, ii, 521 ;
'^Mrans. Natl. Assoc. Prev. Consump. 1913, 148 ; Cent. f. Tub.-Forsch.

1913, vii, G71 ; ^^Brit. Med. Jour. 1912, ii, 793 ; ^^Liverp. Med.-Chir. Jour. 1913,
105 ; and Pract. 1913, i, 296 ; ^^Int. Centralbl. f. Tub.-Forsch. 1913, vii, 408 ;
^^Bevl. klin. Woch. 1912, 2258 ; ^'Hancet, 1913, ii, 376 ; ^Mrans. Natl. Assoc.
Prev. Consump. 1913, 44 ; ^^Freiburger Med. Gesellsch. (Meeting), Nov. 19,
1912 ; ^^Brit. Med. Jour. 1912, ii, 959 ; ^^Pract. 1913, i, 170 ; ^''•Lancet, 1913,
i, 750, and Trans, Natl. Assoc. Prev. Consump, 1913, 82 ; ^^Brit. Med. Jour.
1913, i, 921 ; ^^Lancet, 1913, i, 1487 ; "®j5nL Med. Jour. 1913, i, 213 ; '^^Ibid.
1368 ; "^-Drapers’ Co. Research Mem., viii ; •‘'^Anier. Med. Jour. Sci. 1913, 683 ;
’’Mrans. Nail. Assoc, Prev. Tub. 1913, 298; "^Brit. Med. Jour. 1913, i, 113 ;
”Mrans. Natl. Assoc. Prev. Tub. 1912, 424; ’^“Arch. Int. Med. 1913, ii, 100;
“^Berl. klin. Woch. 1912, 1969.

Part II:— The Dictionary of Treatment.

A REVIEW OF MEDICAL AND SURGICAT. PROGRESS

FOR 19 U. BY MANY CONTRIBUTORS.

Together xcith a brief Synopsis of Treatment recomtuended
during recent years.

CxENERAL REVIEW.

Abdominal Surgery. — The past year has witnessed the widespread
adoption of Crile’s method of “ Anoci-association technique in
abdominal surgery (described in other sections of the Annual), a
principle that demands of the surgeon an infinite care and attention to
detail. When correctly performed, the technique appears to be a
distinct surgical advance, though its true utility cannot be rightly
judged until it has emerged from the glamour of its originator’s sincere
enthusiasm.

The distressing but vague disorders associated with constipation
continue to receive a large share of attention, but surgical opinion is
by no means unanimous as to the most desirable method of treating
these complaints. It is unfortunate that experimental study cannot
be of ihuch value in this instance.

The subtle conceptions of pancreatic disease formulated by Dea\'er
shed an important light on this difficult subject. — [B. G. A. M,, and
H. U.]

* « * Hs

Anaesthetics. — The attention of anaesthetists, so far as new methods
are concerned, is chiefly directed at present towards two processes,
viz., intratracheal insuffiation of ether, and the combined use of general
and local anaesthetics and preliminary alkaloids in accordance with
the principles laid down by Crile under the name of anoci-association.
Both these innovations are likely to find a place, and a considerable
place, in the usual practice of anaesthetics in the future. At present
they are in that stage when, owing to their novelty, they are being
widely employed without that selection of cases which fuller knowledge
is pretty sure to bring. As routine measures in all cases they are
obviously open to many objections. It is equally certain that in
their owm proper fields each of them offers advantages that are not to
to be obtained by any other of the methods in common use. Thus,
one regards intratracheal insuffiation as the method par excellence for
intrathoracic surgery and for many operations involving the mouth

REVIEW

MEDICAL ANNUAL

and nose, whilst Crile’s method seems unrivalled for dealing with
patients in a veiy feeble state and for operations for the cure of
exophthalmic goitre.

Much work has been published during the past year upon various
modifications of local and regional analgesia, and the spinal method
holds its place as a most valuable resource in certain cases. Intra-
venous anaesthesia, after a fuller trial, seems unlikely to compete
successfully with older methods and with those already mentioned.

The physiological work directly connected with anaesthetics that has
to be noticed this year is not very abundant, but mention must be
made of Levy’s most suggestive contribution to the elucidation of the
causation of death during chloroform anaesthesia. — [J. B.]

:1s :!? ^'s

Children’s Diseases. — The methods of artificial feeding of infants
in vogue in different countries are still very dissimilar. The amount
of fermentation in the intestine which various forms of modified
milk are capable of producing is obtaining considerable attention. The
Berlin School of Finkelstein and Meyer (who emphasize the importance
of fermentation as a cause of gastro-intestinal derangements in infants)
is attracting many adherents, and Eiweiss milch, which they advocate,
is being extensively used on the Continent and in America. Much of
the literature on this subject in the past year has been connected with
the value of maltose and its supposed advantages over lactose.

Whilst it is commonly acknowledged that overfeeding is more usual,
a form of diarrhoea and sickness due to underfeeding is being more
generally recognized. Little that is new has been added to the treat-
ment of summer diarrhma, but hypertonic saline solutions have received
a more extended trial. Investigations tend to show that Quinton’s
marine plasma has no definite superiority over artificial saline of the
same strength, and that saline injections are valuable in proportion as
the loss of fluid exceeds the intake.

More stress is being laid upon the preventive treatment of rheuma-
tism and its early recognition. Evidence of the frequency of infection
by the nose and throat has accumulated. Enucleation of the tonsils,
and antiseptic treatment of the mouth, phanmx, and nose, now take
a definite place in the management of rheumatic children.

More statistics are available indicating the vex*y high incidence of
tuberculosis in children as shown by tuberculin tests. That of von
Pirqiiet is chiefly relied upon ; but it appears that it should be em-
ployed more than once in a given case, and that the cases of proved
tuberculosis in which it fails to give a positive reaction are not a fe\^^
Investigations in Edinburgh by Mitchell and Fraser lead them to
believe that tuberculous infection of glands and joints in that city is
chiefly bovine in origin. If this receives corroboration for other areas,
our conception of the importance of bovine infection will be greatly
altered. There is still no agreement as to the value of tuberculin in
the treatment of the disease in children.

NEW TREATMENT

REVIEW

Infection of the urinary tract in children by the Bacilhts coli com-
munis is a condition which has recently come to occupy a prominent
position. It is still most successfully treated by the plentiful adminis-
tration of fluids and alkalies, though some success is claimed for urinary
antiseptics and vaccines.

In the treatment of whooping-cough, a vaccine prepared from cul-
tures of the organism described by Bordet and Gengou has been
employed by several observers, who report favourably on its use.

A new eruption, styled " eczema oris syphilitica,"' has been described
in congenital syphilis. The Wassermann reaction is furnishing evidence
that syphilis and amentia are more closely connected than was formerly
thought. Salvarsan as a remedial measure in congenital syphilis is
still on its trial.

The occurrence of epidemics of so-called catarrhal jaundice has led
to the suggestion that jaundice in children is due to an infection, and
not, as formerly held, to digestive disturbances. — [F. L.]

* ^ ^ :!i

Dermatologv. — The chief dermatological event of this year has
been the session in London of the International Medical Congress with
its important dermatological section. Vaccine therapy in skin diseases,
which was one of the subjects of debate, has been stimulated and
regulated by the work of many observers in all countries. The subject
of alopecia was very fully discussed, and a consensus of opinion expressed
that alopecia areata is not a contagious affection. Much attention
was paid to the prophylaxis and treatment of syphilis, and largely as
a result of these discussions a Royal Commission on Venereal Disease
has been appointed.

A promising advance in treatment of tuberculosis of the skin has
been achieved by experimental work on the model of Ehrlich's
investigation on the chemotherapy of syphilis. Injections of C3^anide
of gold and potassium have been used with success in active and
extensive cases of lupus vulgaris, and in combination with tuberculin
seem to offer a real advance in treatment. The subject is fully dis-
cussed in the following pages, — [E. G. L.]

s;: * jS; • sh

Digesti\-e Diseases. — The awakening of new interest in old prob-
lems by the application of modern methods, which aim at discovering
the perverted ph3"siology of disease, is evidenced by the year’s articles
on constipation, visceroptosis, and chronic appendicitis, the principal
of which are abstracted under those headings. Among diseases of
the stomach, ulcer and cancer have received special attention ; and
some important investigations into rectal feeding are briefly recorded. —
[Ed.]

REVIEW

MEDICAL ANNUAL

General Medicine. — Subjects which are discussed at length in
their appropriate paragraphs are rheumatoid arthritis, fibrositis, perni-
cious anaemia, and leukaemia. The value of benzol in the treatment
of the last-named disease is considered fully. The interest awakened
by recent research into the functions and diseases of the ductless glands
is evidenced by the paragraphs on the pineal and pituitaiy bodies, as
well as by those on endemic goitre and acute thyroiditis. Investiga-
tions into the etiology and general course of various infective diseases,
such as rabies, actinomycosis, blastomycosis, and so on, are also briefly
recorded. — [Ed.]

:!: s!: ^ t\i i\i

General Surgery. — The progressive spirit of surgery shows itself
in two directions : attempts at betterment of treatment hitherto
accepted as good enough, and attack upon organs and diseases till
now looked upon as out of reach. Instances of the former are to be
found in the paragraphs on fractures and post-operative complica-
tions ; of the latter, in those describing surgical treatment of cardiac,
pulmonary, and arterial diseases. — [Ed.]

* *

Gynjecology and Obstetrics. — ^The two subjects which i*eceiv'e
fullest consideration in this volume are the treatment of uterine cancer
and the serum diagnosis of pregnancy ; the latter appears to offer
too many technical difficulties and opportunities for error to be of
general applicability, though from the theoretical point of view it is
full of interest. In regard to the former, it is clear that the gradual
perfecting of operative technique and the introduction of radio-active
methods of treatment have already begun to make inroads upon the
hopelessness of this disease. — [Ed.]

^ ^ ^

Diseases of the Heart and Blood-vessels, — No province of
medicine has gained, or stands to gain, more notably from the applica-
tion of scientific methods to clinical problems, than that of cardio-
vascular disease. Its etiology is becoming clearer, as the accounts
given in this volume of cardiac S5rphilis and of ulcerative endocarditis
bear witness. Additions to our knowledge of the physiological per-
versions involved in cardiac failure are accumulating rapidly, thanks
largely to British work ; examples of these data are described under
the headings, Auricular Fibrillation,” “ Auricular Flutter,” and

Heart-Block.” Armed with this surer knowledge, the practitioner
is on safer ground than heretofore when he is confronted by prognostic
problems. Finally, treatment is becoming rationalized ; the present
volume gives new information as to the uses and limitations of digitalis,
sodium salicylate, and other important medicaments. — [C. C.]

NEW TREATMENT 8l REVIEW

Acute Infectious Diseases. — The most important fact of the past
year is Behring's announcement of a new prophylactic against
diphthei ia. This is a toxin-antitoxin mixture of a certain constitution,
which has the effect of producing ver^’ large amounts of antitoxin when
injected into the human subject (active immunization). Persons who
have had diphtheria previously are especial!}^ susceptible to the action
of this mixture. The serum from a case thus actively immunized has
been used foi passive immunization of another person. But this last
method of immunization is not one to be recommended. Whether
Behring’s new method will fulfil expectations, remains to be seen. At
the present time the only method of immunization against diphtheria
is by the injection of antitoxic serum (passive immunization) ; and
its effects are known to be merely temporary. Will those of the
new method be more lasting ?

The reader’s attention is directed to Park’s experiments on the
dosage of diphtheria antitoxin. They point to the conclusion that one
moderate or large dose given, when the patient is first seen, is more
efficacious than repeated small doses.

It has now been found that the so-called inclusion bodies ” are
not confined to scarlet fever, as was at first stated. It can now be
taken as established that scarlet fever can be communicated to the
anthropoid apes. But the cause of the disease still bafffes investigation.

The lecords of the use of antit^’phoid vaccination in the United
States, and especially those of the army, confirm amply the favourable
results which have been observed in the English Army in India.

In the article on typhoid fever will be found an account of further
experiences in the dieting of patients suffering from that disease, and
especially of those who dislike milk. Views on this subject have
altered very much during the past few years. — [E. W. G.]

:{! ^ - 4 : i'fi

Nervous Diseases. — The most important new fact in neurology
within the past year has been the discovery, by Noguchi, of the
syphilitic spi’-ochcete in the cerebral cortex of general paralytics.
This breaks the barrier between S3'philitic and para-syphilitic affec-
tions of the nervous s^'Stem. The treatment of general paratysis and
of tabes continues to occup}^ various workers, and fresh methods are
discussed. The study of epidemic poliomyelitis has also been advanced
b\^ Flexner and Noguchi’s discoveiy^ of a globoid organism which
apparenth" is the cause of the disease. Salvarsan and its methods
of empiojmient in cerebrospinal syphilis, together with the curious
nerve-relapses which in nonmervous syphilis occasionalh" follow sal-
varsan administration, are also referred to. Amongst other articles
will be found those on caisson disease, tetanus, epileps^^^, ischaemic
myositis, etc., together with a discussion on the legitimate uses of
suggestion in therapeutics. — [P. S.].

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MEDICAL ANNUAL

Diseases of Throat and Nose. — The diagnosis and treatment of
diseases of the oesophagus and air passages are the subjects which
perhaps have created most interest among specialists ; and cancer of
the oesophagus, even of its thoracic portion, can no longer be said to
be wholly out of reach of the surgeon. In suspension laryngoscopy
we owe to Killian an invaluable new method of directly inspecting
the larynx.

The relative merits of tonsillectomy and tonsillotomy still give rise
to much discussion, with a strong bias in favour of the former ; but
the various operations for carr3dng out tonsillectomy are still legion.
-~[W. G. P.].

Ophthalmology. — A few years ago the weight of ophthalmic opinion
as to the best operation for chronic glaucoma was decidedly in favour
of iridectomy. At present it may be said to have declared in favour
of sclero-corneal trephining. This is largely due to the improvement
in the technique of the operation, and especially to the splitting of the
periphery of the cornea, which we owe to Colonel Elliot, of Madras.

The frequent dependence of certain ocular diseases, and especially
of inflammations involving the uveal tract, on general toxaemia, has
been much emphasized in recent discussions. By far the commonest
source of tox,acmia in these cases, it seems, is a diseased condition of the
teeth, generally pyorrhoea alveolaris. More on this subject will be
found in the article dealing -with diseases of the iris, ciliary body, and
choroid.— [A. H. T.]

Important investigations by Dr. Burdon-Cooper in respect to the
pathology of cataract are fully described and illustrated by the
author. — Ed.

^ s!:

Renal Diseases and Diabetes. — ^IMuch attention has been devoted
during the year to the estimation of the renal functions by the phenol
sulphonaphthalein and other methods, and the bearing of- the results
on diagnosis and prognosis. High arterial tension in nephritis is fully
discussed. Excellent results are quoted from the use of periods of
protein-free diet in nephritis. Proteinuria has received considerable
attention, and reproductions will be found of photographs of a remark-
able case of multiple m^’elomata. Important work has been done in
urinary antiseptics. Diabetes insipidus is considered in articles which
throw light on its pathology and its relation to the pituitary gland.
Diabetes mellitus formed the subject of a discussion at the International
Congress in London, and a number of articles have appeared in the
journals. Though no great advance in pathology or treatment can be
claimed, still our knowledge slowly progresses towards a better under-
standing of an absorbing and important disease picture. -"[F. D. B.]

NEW TREATMENT

REVIEW

Tropical Diseases. — The most noteworthy event is the discovery
that pellagra is widely prevalent in Great Britain, while much valuable
research has been done on this disease in the United States ; it has
therefore been made the subject of a special article. Sir David Bruce
and his fellow-workers have established the identity of Trypanosoma
brace i of nagana in cattle with T. rhodesiense of the recently discovered
second variety of human sleeping-sickness, which will necessitate the
desti’uction of the infected wild game in portions of Africa. The
great value of the emetine treatment of d^^sentery has been estab-
lished by extensive experience in many parts of the world, and a new
specific drug is thus added to the ver^^ small number previously known ;
although more prolonged treatment may be necessar}^ in some cases
to prevent relapses than was at first hoped might be the case. The
value of the hypertonic saline treatment of cholera has been confirmed
by further experience in India and in China. A new species of hook-
worm affecting man has been found in India, which is also commonly
met with in certain domestic animals ; this complicates the proph3daxis
of that disease. Important experimental work, throwing much light
on the etiology of plague pneumonia, has been recorded b}^ Strong
and his colleagues in the Philippine Islands. — [L. R.]

t\i ilt :|s s’s

Urinary Surgery — The literature of the year contains no new
departure in diagnosis or treatment, but methods already recognized
are being tested. The skiagraphic demonstration of vesical tumours
and their removal by transperitoneal operation or b}^ high-frequencj?’
treatment, and stone as seen in Eg\"pt, and its treatment b}* litho-
lapaxy and b}? open operation, are discussed. Some attention has
been paid to the surger}’ of single, horseshoe, and d^^stopic kidne^^s.
Moore and Corbett have continued their valuable investigations into
the damage to the kidney' caused bj- operation and method of suturing.

Supiapubic prostatectomy, which has in this country superseded the
perineal operation for simple enlargement, is the subject of articles by
American surgeons who advocate the method. Wilms’ method of
perineal prostatectom}’ by lateral incision is also described. Young
describes a “punch” operation which ma^- prove useful for “ small
prostatic bars and contracture of the prostatic orifice.”

The role of the prostate and seminal vesicles as primary foci of
infection in chronic toxaemias and remote infections is discussed.
Variations in operative procedure in h^-pospadias and in urethral
defects after operation are described. — [J. W. T. W.]

:!; i\t j’! jJ:

Venereal Diseases. — In the domain of syphilology much work
has been done, both in pathology and treatment. Perhaps the most
noteworth^^ fact is the disco ver^^ by Noguchi and Levaditi of the
SpifochcBta pallida in the brain and spinal cord in cases of general
paratysis and tabes, a discovery which ma\’ modify our conception of

REVIEW

MEDICAL ANNUAL

these diseases. Noguchi has also given further demonstration of the
culture of the S. pallida and other spirochaetes. Further observations
liave been made on the life history of the parasite of syphilis by E. H.
Ross, McDonagh and others, tending to show that the spirochsete form
is only one phase in its life cycle, and that it goes through a resting or
spore stage, which would explain the long latent periods in S3rphilis, and
other points hitherto obscure. It is necessary to mention, however,
that a similar life cycle was described by Maclennan in 1906.

As regards treatment, salvarsan is still extensively used, generally
in conjunction with mercury, but it has rivals in the form of , new
arsenical preparations invented by Mouneyrat, which are said to be
equally efficacious and less toxic. Moreover, the claims of antimony
as an antisyphilitic drug are urged by Tsuzuki, who reports good
results with a preparation of antimony similar to salvarsan in its
chemical construction. No doubt other drugs and combinations of
drugs will be introduced ; but it is well to bear in mind that all
these new therapeutic measures are on their trial, and that years
must elapse before their individual or relative merits or demerits can
be established — [C. F. 1\’L]

ABDOMEN, GUNSHOT WOUNDS OF.

Sir Berkeley Moynihaiif M.S., F.E.C.S.

Harold Upcott, F.R.C.S.

Kahn’s^ article is based on thirteen cases in his own civil practice.
He says that a greater number of visceral perforations may be expected
if the bullet traverses the abdomen transversely or obliquely than if
its direction be aiitero- posterior. In every case of penetration of the
abdomen by a bullet, multiple perforations of the viscera are to be
assumed, and prompt surgical exploration is demanded. Kahn does
not think that deductions dravm from militar^?^ experiences should be
applied in civil work. IMost army surgeons agree that more bullet
wounds of the abdomen end favourably w-ithout than with operation ;
but several factors contribute to the bad results of operation in time
of w'ar, such as the delay and difficulty of transport, and the poor con-
ditions often surrounding the operation. Probably, also, many cases
die on the battle-field and so evade the statistics. In ordinary practice,
when the bullet has clearly entered the abdomen, it is unwise to await
symptoms. The chief difficulty arises when its wound of entry is so
placed that its further course is uncertain. It is then necessary to be
guided by symptoms, of which pain and muscular rigidity" are the most
important.

As a rule, the abdomen should be explored through a free median
incision. If there is profuse haemorrhage, its origin should be at once
sought ; when the bleeding is controlled, the viscera should be examined
for perforations. If the bleeding is inconsiderable, the repair of perfora-
tions should be the first care.

Shot wounds of the intestine usually permit little extravasation

NEW TREATMENT

ACANTHOSIS NIGRJCANS

during the early hours following injury, whereas wounds of the urinary
bladder and gall-bladder, and large wounds of the stomach, allow an
immediate escape of their contents. The perforation of any hollow
organ usualh' involves two penetrations of its wall; hence an even
number of holes should be sought.

Hsemorrhage from the liver is generally controlled by catgut or tape
suture. Haemorrhage from the spleen, if not controlled by packing
or suture, calls for splenectomy. Sevex-e injuries of the kidney* are to
be treated by nephrectom}’. Lesser wounds may be treated by suture,
and drainage from the loin.

Reference. — ’'■Jour. Amer. Med. Assoc. 1913. i, 955.

ABDOMINAL WALL, LIGNEOUS PHLEGMON OF.

S/r Berkeley Moyniha^i, M.S., F.R.C.S.

Harold Upcott, F.R.C.S.

B}’ ligneous phlegmon is meant a hard, board-like, painful induration
in the subcutaneous connective tissues, w'hich runs a very chronic
course extending over months or years. Grants reports t\vo cases,
one following a herniotom}- and the other occurring in a patient after
an attack of appendicitis.

The disease occurs general!}" after middle life, and when resistance
has been impaired by previous ill-health. The immediate exciting
cause is a slow infective process, with or without trauma. It appears
to be due to a variety of germs of lessened virulence, and affects con-
nective tissue, fascia, muscles, and finally skin.

The diagnosis is often exceedingly difficult, and malignant growths,
syphilis, and tuberculosis have to be eliminated. The usually slow
development, interrupted and protracted course, and final resolution,
are characteristic.

Grant considers the best treatment to be free Incision and the
injection of Vaccines dkectly into the hardened tissues.

Reference. — ^Jouv. Amer. Med. Assoc. 1913. i, 1039.

ACANTHOSIS NIGRICANS. E. Graham Little, M.D., F.R.C.P.

Klotz and Rohdenburg^ report a new case of this rare disease, which
was followed to its termination in visceral cancer, the usual association.
The patient was aged sixty-two at the first appearance of the cutan-
eous ahcction, vdiich showed itself in pigmentations of the hands, neck,
axillffi, and genital area; in warty groAvths in various parts of the
body ; in thickening of the skin, which became shark -like ” on the
hands ; and in thinning and loss of hair. There tvas at first marked
improvement under Arsenic administered by the mouth and subse-
quently hypodermically. About eighteen months after the cutaneous
changes appeared, a small tumour was noted in the sigmoid flexure, and
subcutaneous nodules developed. These continually increased in
size ; operation was declined, and the patient died six months later.
The intestinal growth and the skin nodules alike were demonstrated
to be spindle-celled sarcomata. The case recalls very strikingly,' in

ACANTHOSIS NIGRICANS

MEDICAL ANNUAL

all its details, including the intestinal malignant growth, the one
recorded by the writer in the Medical Annual, 1910, with a coloured
plate illustrating the clinical aspect of this disease.

Reference. — ^Jonr. Cut. Dis. 1913, 306.

ACNE VULGARIS. E.. Graham Little, M,D., F.R.C.P,

Haase^ reviews the very conflicting literature on the bacteriology
of this disease, and comes to the conclusion that the confusion is due
to observers having reported on different stages of growth in the same
organism. He is inclined to agree with Gilchrist that B. acne is the
cause of all the various clinical manifestations of acne, comedo, and
pustule.

He is satisfied of the value of acne Vaccine, which he has always
used ill stock cultures, and inclines to the small doses (3 to 5 millions)
recommended by Engman and others. [See also Skin, General Thera-
peutics OF.]

Reference. — Jour. Amer. Med. Assoc. 1912, ii, 504.

ACTINOMYCOSIS. Herhert French, M.D., F.R.C.P.

A considerable number of new collected cases of human actino-
m3:^cosis have been recorded by Foulerton^ (78 cases) and McKenty'^
(47). The former lays particular stress on the fact that in man}’',
an exact diagnosis on clinical evidence is impossible. In pulmo-
nary infections the clinical symptoms and signs are those of chronic
phthisis, and it is only the occasional perforation of an intercostal
space, possibty with subcutaneous extension of the infection, that
may help in differentiating a case from one of infection b}" Koch’s
parasite. In only one of the fourteen cases of pulmonar}^ strepto-
trichosis examined at the hospital was there slyiv suggestion that the
disease was other than an ordinaiy tuberculous phthisis, until suspicion
was I’aised b}^ failure to find t\^pical “ tubeixle bacilli ” in the sputum,
or until typical mycelial forms of a non-acid-fast streptothrix had been
identified in the sputum. Equally, a diagnosis b}’ clinical methods
of the specific kind of infection is impossible in acute streptotrichial
infection of the appendix, or in an}^ case unless there has been extension
to the subcutaneous tissue. In the case of mouth infections, whilst
there is nothing characteristic about the local abscesses which form in
the cheek or neck, the situation of the swelling, and sometimes the
occupation of the patient, may suggest a diagnosis.

Difficulties in the wa}^ of the positive identification of the parasite
by lahorator}^ methods arise from two sources : in the first place there
is the extreme difficult}” of obtaining growth of many parasites of this
class on artificial media ; and in the second, that arising out of the
varying morphology of these species of moulds at different phases of
their life-cycle. It is now well recognized that the mycelial, or ray
fungus ” form, represents only one of the three forms under which these
parasites occur ; and this typical mycelium, and the mycelium when,
in the earlier stages of fragmentation,” it is breaking up into ” rod
forms,” represent the only stage at which the parasite can be recognized

NEW TREATMENT

ACTINOMYCOSIS

positively by microscopic examination. At a later stage of develop-
ment, when fragmentation of the m3xelium is complete, and when
sporiilation has occurred, the picture is no longer that of a '' ray fungus ”
— all that can be seen in a stained film is a collection of somewhat
irregular bacillar}’ " forms, and spherical spores which exactly
resemble the common pus cocci ; and both forms stain deeply with
Gram's method.

McKenty also shows how much more common human actinom\’cosis
is, especially in rural communities, than is generally supposed. It is
often mistaken for tuberculosis or new growth, on account of the
difficulties of exact bacterial verification, or because the proper bacterio-
logical investigations are not carried out as often as they should be.
He gives a full account of the mode of origin of the pathological lesions
that result from the infection. The incubation period varies from a
few da\’s in some jaw cases, to weeks or months in abdominal and
pulmonary cases. In the latter, phthisis is generally simulated and
diagnosed. The disease spreads by contiguit}^ and along the blood-
stream, rarely by l^^mph-channels. The pus from the cavities is small
in quantit^^ has a peculiar earthy odour is usually blood-stained,
and contains the characteristic sulphur-^^ellow granules, which in cattle
possess a very gritty feel, and are found under the microscope to be
colonies of the organism. The central part of a colony consists of a
mass of filaments (m\’celium) which form a dense felted network. At
the periphery there are large pear-like forms which have received the
name of clubs ; coccus-like forms (probabty cross- views of filaments)
are also present. The clubs appear to be the swollen terminal extremi-
ties of the filaments. They are more frequently met with in cattle
than in man, and are more abundant in chronic cases. The organism
grows with so much difficult}^ on all ordinary media that cultural
methods are of no practical value to the clinician.

Treatment.. — The curative value of Vaccines in cases of actino-
mycosis is emphasized by Collie.® His patient was confined to a couch,
pale and emaciated, Avith a large suppurating actinomycotic abscess in
the left iliac fossa, a second in the left costal margin in the nipple line,
and a third between the shoulders. Potassium iodide had been given
freeh’, but wholl\^ without effect. The patient v'as wasting rapidh’,
and hope of his cure had been given up. Stock \'accine was then
resorted to, and between November and March he was given seventeen
injections in all, in doses of between five and seven and a half millions.
The last feAv inoculations were autogenous, the remainder from stock ;
improvement set in soon after the treatment was started, and within
six months the man was back at work ; he had put on weight, looked
the picture of health, the groin trouble had disappeared entirely, and
the two other places were almost gone, though at the time of reporting
they were still present as small healing Avounds.

References. — '^Lancet, 1913, i, 381 ; -Amev. Jouv. Med. Sci. 1913, i, 835
Med. Jour. 191^, i, 991.

ADENOIDS

MEDICAL ANNUAL

ADDISON’S DISEASE.

{Fol. igi3, p. SQj—'Mimro recorded’ a case in which prolonged administration of
Tntoercuim appeareri to effect a cure.

ADENOIDS. TF. G. Porter, M,B., F.R.CS,

Sobotky^ points out that in a considerable number of cases mouth-
breathing persists after the removal of adenoids, and that in such cases
the nasal breathing exercises have not proved efficient. Operative
treatment of the nasal condition, e.g., reduction in size of the turbinals,
is then indicated. If the palatal arch is high, spreading the arch and
regulation of the teeth are of value.

Grove^ has met with two cases of infection of the nasal accessory
sinuses following the removal of adenoids, in one case of the frontal
sinus and in the other of the anterior ethmoidal labyrinth. Infection
appeared two weeks after operation. He refers to other complications
which may arise, viz,, general septicaemia, all of the acute infectious
diseases of childhood, adenitis, erysipelas, post-operative lung infec-
tions, and meningitis. He concludes that more care should be taken in
after-treatment than is usually the case, and if possible the patients
should be admitted to hospital and not treated as out-patients. Jolly^
records a case of osteomyelitis of the sphenoid hone following removal of
adenoid's in a child, aged 5. He was seen by the author seventeen days
after the operation, which had been performed elsewhere, apparently
suffering from septicaemia and with symptoms of cavernous sinus
thrombosis. He died in four days, and at the autopsy the entire body
of the sphenoid bone was found to be broken down and infiltrated
with pus, and there was widespread basal meningitis. The infection
had apparently started in the nasopharynx.

Treatment of Adenoids without Operation, — Ashby^ believes that
adenoid hypertrophy is an attempt to make up for deficiency in the
other lymphoid tissue of the bodj". He has accordingh- treated these
cases wdth Lymphatic Gland Extract, and believes he has had good
results.

References . — ^ Bost. Med. and Siirg. Jour. 1913. 1,230; ^ Johns Hop,

Hasp. Bull. 1910, 1 12 ; ^Lancet, 1913, i, 1734 ; ‘^Brii. Med. Jour. 1913, i, 1159.

ALBUMINURIA. Francis D, Boyd, M.D.

Its Relation to Life Insurance . — ^All are familiar with the albuminuria
of adolescents. If the cases be followed up through life, it is found that
albuminurics in their teens and twenties lose the abnormal symptoms
in later life. It is important from the life insurance point of view to
separate such cases from those in which the albuminuria is a sign and
a part of grave organic disease.

R. Scot Skirving’s experience of one year included the following
totals of albuminurics examined : —

Se\ 15 years or i6 lu U\ei Tutal

Male Female under 25 25 lives

141 ^5 17 112 27 156

Of the total lives applying for insurance, the albuminurics form 2
per cent. In classifying any case as functional and not organic, the

NEW TREATMENT

ALOPECIA AREATA

following points are of importance : (i) Absence of any recent cause
for nephritis, such as exanthemata, diphtheria, or a clear history of ordi-
nary antecedent acute nephritis with its classical signs ; (2) Absence
of any of the ordinary stigmata of chronic renal disease, especially
cardiovascular changes ; (3) The fact that the proponent is under twenty-
five, and presents a healthy appearance ; (4) That the urine is of a good
or even high specific gravity' ; (5) That the albumin is very slight or
moderate in amount — ^that it is not constant, i.e., it is often absent
at certain hours of the day, and its appearance is frequently" influenced
by exercise, by food, or by cold ; (6) That microscopical examination
of the urine reveals no important suggestive abnormality ; (7) That
the blood-pressure is not unduly high.

If the facts taken generally are in favour of the proponent, and he
or she is under twenty-five years, life may be accepted at rate for age ;
if the proponent is over twenty-five and under thirty, the proposal in
some cases may be accepted at ordinary rates, or with a moderate
loading. If over thirty, the life should be deferred or heavily loaded.
From an actuarial standpoint, according to the author, calculations
show that if out of 100 lives diagnosed as functional albuminurics
the medical examiner classes 50 as select, and 50 not quite select,
and of these latter, 10 cases turned out badly and died, say at one
half their expectation of life, while the remaining 40, together with
the 50 taken as select, lived out their full expectation, it would then
be necessary for the protection of the society to load the whole 50,
which are not definitely first class, at the rate of about five years.

MacLaurin^ urges that all adolescent albuminurics should be classi-
fied as increasing risks, because, while there is abundant evidence that
they may reach middle life in safety, e\"idence is wanting as to their
progress after the forties ; and, moreover, it is certain that in a fair
proportion the albuminuria is due to some latent condition of ill-health,
such as carious teeth, or some other toxaemia which is not likely to
conduce to long life. As scientific selection is impracticable in life
assurance work, the fairest way to treat all apparently healthy young
albuminurics is to lump the good with the bad, and classify them all as
increasing risks, and insure them under a double endowment table
specially adapted for such. The polic}' of loading them all to five years
jMacLaurin does not approve of, because at the age of fifteen to eighteen
a three to five years’ loading is so trifling as to have little effect beyond
irritating the proponent, and is really not worth putting on.

In cases where there is a possibility that real organic disease, though
latent, may be present, it is wise to propose three to four years’ condi-
tions, i.e., if death occurs within three to four years, to return the
premiums with 3 per cent compound interest.

Reference. — ’^Austral. Med. Gaz. 1912, 455.

ALOPECIA AREATA. E. Graham Utile, M.D., F.R.C.P.

Pellizari^ regards alopecia areata as of complex causation, in which
the nervous factor predominates ; it must be looked upon as a
symptom of general illness, a view in which he was supported by many

ALOPECIA AREATA

MEDICAL ANNUAL

speeches in the subsequent discussion. He found good results in
many cases from treatment by High Frequency, which, however,
failed completeh^ in some. The application of Violet and Ultra-Yiolet
Rays, of X-rays, manual and instrumental Massage, Bier's Method of
inducing hyperaemia, and Freezing by carbon dioxide snow are also
mentioned as having given good results.

Sabouraud'-^ claims that alopecia areata can no longer be regarded as
an infectious disease after Jacquet's work on the subject, but he regards
that author’s reflex theory as true only of a certain pioportion of cases,
cliiefly of those of scanty and unilateral distribution. The more widel}'
spread cases are symptomatic of a general disease, which is also marked
by changes in the nails, and frequently associated with \dtiligo, lupus
erythematosus, psoriasis. Graves’ disease, tuberculosis, syphilis, and
other general infections. There is a group of causes which may be
classed as genital, comprising the menopause in women, and castration
in men. Alopecia is hereditary in 25 per cent of the cases recorded.
The most promising advances in treatment would follow from an
investigation of the connection of the disease with disorders of secretion
of the internal glands. Emlpi Jones^ made an interesting comparison
of 50 cases of alopecia areata with 50 cases of surgical out-patients.
The incidence of dental caries was much the same in both, series. He
considers that Jacquet’s theory of reflex ner\e irritation as explainmg
alopecia areata rest.s on too slight evidence to be very convincing.

References. — ^Proc. Intermit. Coiigr. Med. Section xiii, pt. i, 15 ; ’^Ibid.
23; Jour. Dermatol, xxiv, 3O2.

AMiEBI&SIS. Leonard Rogers, M.D,, FJLC.P.

Etiology. — A good deal of confusion still exists regarding the varieties
of enlamorhev and their differentiation from each other. The present
tendency is to atti'ibute amcebic dysentery mainly to E. tetrageiia,
while doubts are tlirown on the correctness of Schaudinn’s description
of E. histolytica. Darling^ now thinks that the former is the only
pathogenic amoeba found at Panama. The diagnostic point of E.
tetragena he considers to be the presence of chromatin in the protoplasm
outside the nucleus. In kittens fed on E. tetragena c^’sts the disease
was produced, with forms resembling both E. histolytica and nipponensis.
In stools of recovering cases, small refractile homogeneous cysts are
found, 15 microns in diameter, which after a day or two in a moist
chamber develop two to four nuclei, and young amoebae are formed
later. As these cysts only are infective, they should be sought for.
He has confirmed the fact that the commonest site of amoebic ulcers
is in the caecum, when ill-defined abdominal pain and some diarrhoea
are alone present. In a further paper- he points out that polychrome-
blue eosin stains gi\'e a purple colour to quite a different part of the
nucleus from that which is deeply stained by haematoxylin, which may
be a source of confusion if not carefully borne in mind.

\V. ;M. James'* deals with the identification of entamoebae by simple
clinical microscopical methods in unstained samples of stools. In the

PLATE IV.

AMCEBl ASIS

MlUnC.At .iXNV.AL, 101!

NEW TREATMENT

AMCEBiASIS

harmless E, coli the nucleus is plainly visible, generally rather central,
while it retains its circular shape during movement of the organism.
The endoplasm is always grey, and only slightly differentiated from the
ectoplasm during motion, with extruded pseudopodia. On the other
hand, in E, histolytica the nucleus has scanty chromatin, so is not
easily seen, and it becomes elliptical during movement. In E, tetra-
gena, however, the nucleus is prominent as in E. coli. The ectoplasm
of E. histolytica and tetragena is clearly differentiated from the endo-
plasm, while movement is more rapid with well-defined pseudopodia,
which is quite distinctive from E. coli. The endoplasm is commonly
of a greenish tinge and contains numerous red corpuscles. James has
seen many patients treated with quinine enemata, etc., when only
harbouring the harmless E. coli and without bowel symptoms, although
colitis often developed as a result of the treatment, so the simple
differentiation of the harmless from the pathogenic entammbre is
important. Craig* has recently altered materially the views ex])ressed
in his work on amoebai, and now considers that E. histolytica and R.
tetragena are one and the same species, having found all the stages
hitherto described in either species in single infections.

L. Rogers** deals with the monthly distx'ibution of dysentery in
relation to the rainfall in different parts of India, clearly showing the
increase of the disease during the monsoon rains. The proportion of
liver abscess cases to dysentery is very uniform in the British army
throughout India, proving that amoebic dysentery is very widespread.
Since he sliowed that large doses of ipecacuanha would ]u*evcnt early
hepatitis, the number of cases and deaths from liver abscess has greatly
fallen among British soldiei*s in India. Amoebic disease of the bowel
frequently causes no symptoms apart from diarrhoea, and in Calcutta
no less than 40 per cent of the fatal cases as seen post mortem had not
been diagnosed or treated as dysentery during life, but wore usually
returned as diarrhoea ” and “ tuberculous diarrhoea.” The importjiiic<.‘
of examining the stools of all diarrhoea cases for nmadxe in warm
climates is thus clear. In the majority of cases of aincehic (listen, se
the organisms can be found within a few minutes by a simple
scopical examination of the stools, but in some, especially in chronic
disease, repeated examinations arc nece.ssary to detect them. W'iuui
they are scanty, the search is facilitated by adding a drop of 1 per cent
watery methylene blue to a piece of mucus and first searching with a
low power (-|-in. lens). In such specimens the cells stain blue, but for
a time the amoebai remain unstained, and lienee arc* easily foum.l with
a little practice {Plate IV).

M. Couteaud** deals with secondaiy abscesses in the brain related
to suppuration in the liver and lungs, some of which were apparently
amoebic in origin.

Treatment. — L. Rogers" records further experience of his Emetine
treatment of amoebic dysentery. He compares the results of 30 cases
treated with ipecacuanha with 26 who w'ere given hydrobromide and
hydrochloride of emetine hypodermically. Of the 30 ipecacuanha cases,

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II died and 2 were removed by their friends in a dying condition.
Of the II, 4 died within three days of admission in a hopeless state.
Of the total, 13 were discharged cured and i much improved; 3 more
were discharged no better. Of the 26 emetine cases, 2 died within
two days of admission in a hopeless condition. Two more recovered
completely from the dysentery, but died of other diseases. The
remaining 22 were all cured, their stools becoming normal in an average
of 2*35 days, against 11*4 days in the cured ipecacuanha series, and
they were discharged in an average of 7*2 days, against 16*4 days by
the older treatment. No cases were discharged uncured. The
average dose of emetine hydrochloride to cure a patient was 2 gr.,
against 406 gr. of ipecacuanha. He discusses the question of the
permanency of the cures, and records evidence in patients dying later
of other diseases to show the amoebic ulcers had completely healed,
but considers it too early to answer the question in the affirmative,
although so far all the evidence points that way. He has given up to
one grain of the hydrochloride intravenously, dissolved in 90 min.
sterile saline, with good effect and no sickness. Given by the mouth in
salol-coated pills, emetine is much less effective than hypodermically,
while one case relapsed in a few days.

W. Allan® records two cases confirming the above results. One
was remarkable for the fact that 50-gr. doses of ipecacuanha in salol-
coated pills had failed after full trial. The first hypodermic dose of
the new drug caused great pain and did no good, and was found on
analysis to contain no emetine. Ipecacuanha again failed, but a fresh
supply of emetine eventually cured the patient, although not until a
4-gr. dose had been given, [It would be interesting to know the
weight of the man. — L. R.] J. W. Lawson^ records a case of amoebic
dysentery of ten years’ duration cured in a few days by a total of
2 1 gr. of emetine hydrochloride in nine doses. J. Preston MaxwelP®
gives notes of ten cases, and concludes that the claims put forward
have been abundantly justified, for whereas he formerly dreaded the
arrival of these cases, he now welcomes them. Amoebae were found
in the stools of each before treatment, but they rapidly disappeared.
All the cases were cured, and he had seen no relapse. A. C. Hutcheson’-^
also reports 13 cases, and concludes that emetine in amoebic
dysentery is w’onderful in its efficacy. In 2 out of 3 cases of
schistosomum infection the blood disappeared from the stools in six
days under emetine, but in the third case it failed. R. Lyons^^ also
reports favourably on 6 cases with no relapses up to date. G.
Baermann^® has recorded most important observations on emetine in
amoebic dysentery in Sumatra, having been able to follow up his cases
for considerable periods. Some were in a very advanced stage of the
disease, and, although the symptoms cleared up, the patients eventually
died from the damage already inflicted on the bowel wall, as in some
of Rogers’ earlier cases. He used the drug intravenously in severe
cases, as advised by Rogers, with good effects. Occasionally in fatal
cases a few encysted amoebae were found surviving in the bowel wall,

NEW TREATMENT

AiVICEBiASiS

thus accounting for occasional relapses. He therefore advises the
emetine injections to be continued every few days for some little time
after the symptoms have disappeared, to prevent relapses. He con-
cludes that the new method is a very important advance, and leads
to an effective treatment of amoebic dysentery, the scourge of the
East.

Chauffard^^ has also confirmed the remarkably rapid specific action
of emetine in both amoebic dj^sentery and liver abscess. In one patient,
who had been coughing up much liver pus for several months without
improvement, a cure was effected with emetine in a few days. The
same writer^** reports another case of hepatic abscess with copious
discharge of pus through an operation w'ound in the chest wall, in
which, when little progress was being made, the discharge ceased in a
very few days under subcutaneous injections of emetine. Rouget and
Flandin record similar good results in Madagascar. Milian obtained
good results from emetine injections in some cases of syphilis, but it
failed in others.

S. Mallannah^^’ records a case of large liver abscess following dysen-
tery, in which after three aspirations the patient was still very bad
and refused the open operation. Under emetine by the mouth, the
fever ceased, the diarrhoea stopped, and' within a month the liver
became reduced to its normal size and the patient recovered, having
taken 21 grs. of emetine in J-gr. doses.

VerteuiP^ records a remarkable case of amoebic dysentery compli-
cated by liver abscess on three occasions, and lasting three years and a
half, which -was cured in a few days by injections of emetine hydro-
chloride. G. C. Low^® found emetine by the mouth, in keratin-coated
pills, effective in a mild amoebic dysentery. J. H. C. Thompson^®
records his experience on tea estates in Cachar during the last seven
years, where in some places as much as 25 per cent of the sick list is
due to dysentery. The ipecacuanha treatment was often refused on
account of the sickness induced. Emetine, on the other hand, has
been found verj^- satisfactory, and as no less than 85 per cent of the
cases were ammbic, he considers that “ we have in the treatment of
dysentery by injections of emetine hydrochloride, a powerful, reliable,
and scientific method, the value of which it would be diflicult to esti-
mate." Sir C. P. Lukis,-^ in the bacillary form, relies on vaccines, anti-
dyseiiteric serums, and salines, and in the amoebic on hypodei'mic
injections of emetine hydrochloride. M. Maurin**^^ has obtained good
results with an enema of 4 grams of ipecacuanha in 200 grams of .water
daily in one case of amoebic dysentery^, which was cured in about
eleven days. F. F. Elwes, Webster, and Ingrain, working at the
Madras General Hospital, testify to the valuable effects of emetine in
amoebic dysentery and hepatitis. D. C. H. MacArthur^® cured a case
of hepatitis and a liver abscess with the drug.

S. H. Wadhams and E. C. HilP-^ record three cases of amcBbic dysen-
tery treated with Salvarsan, in only one of whom was the Wassermann
reaction positive, yet the dysentery appears to have been cured in

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MEDICAL ANNUAL

each. The authors consider the cases too few to draw conclusions
from, but think it worthy of further trial.

L. G. Fink'*^^ reports a case of liver abscess treated by a modification
of Rogers’ method of Aspiration and injection of Quinine. Fink used
a trocar and cannula for evacuating the abscess ; he irrigated the cavity
with sterile saline and injected the quinine solution, and repeated the
operation on subsequent occasions, with ultimate recovery of the
patient.

H, G, Beck2« suggests using Einhorn’s duodenal tube for getting
ipecacuanha into the intestine. A two-ounce metal syringe was used
to instil the remedy, which consisted of one to two drachms of ipecacu-
anha in mucilage or water in a six-ounce mixture. The results were
good in severe cases, being better than by oral administration.

W. E. Deeks 27 records further good results with his Bismuth treat-
ment, which was described in last year’s Annual. During the past
year only 21 out of no admissions to the Ancon Hospital were found
to be due to the E. histolytica, which is the cause in nearly all his cases.
In one case, in wdiich the E. ietragena was present, it ^vas found that the
bismuth method was powerless. He thinks bismuth acts by removing
putrefactive changes in the large bowel, which are essential to the
protozoal parasites, and which persist longer in the appendix than in
the CrTccum. In the thirty months up to December, 1911, 74 cases had
been treated, with g deaths, mostly from complications such as liver
abscess. Among 65 cases under the bismuth treatment, only i died.
Relapses and hepatic complications were also prevented by the treat-
ment, of which saline enemata and milk diet form an important part.

References. — ^Proc. Canal Zone Med. Assoc. 1912, iv, Pt. ii, 122 ; ^Joiir.
Trop. Med. and Hyg. 1912. 2 ; ^Ihid. 132 ; ^Jonr.Amey. Med. Assoc. 1913, i, 1353 ;
^Lancet, 1912, ii, 1062; ^Rev. de Chiy. 1913, July, 56; ’^TJier. Gaz. 1912,
838, and hid. Med. Gaz. 1912, 421 ; ^Jour. Anter. Med. Assoc. I9i3> i> ^^4 ;

Med. Jour. 1912, ii. 793 ; '^^Cliina Med. Jour. 1913, Mar. ; 191.L

243; Jour. Amer. Med. Assoc, xgx^, i, 1216; med. Woch. I9I3»

1132 and 1210 ; '^■^Pvesse MM, 1913, 389 ; '^'•Jonr. Amer. Med. Assoc. 1913, i,
1S96; Med. Jour, xgi^, i 1206 ; Lancet, 1913, i, 1S03 ; ^*^Brif.

Med. Jour. 1913, i, 1369 ; ^^Dnblin Med. Jour. 1913, ii, 102 ; -^Brit. Med.
Jour. 1913, i, 3157; -^Lancet, 1913, ii, 942; Incl. Med, Gaz. xgx^, 324;

Med. Jour. 1913, ii, 551 ; ^*Jouy. Amer. Med. Assoc. 1913, ii, 385;
^^Jquv, Trap. Med. and Hyg. 1912, 359: '^^Jour. Amer. Med. Assoc. 1912. ii,
2110; 1913, i, 38.

AMPUTATIONS. Priestley Leech, M.D., F.R.C.P.

Estes^ has studied the results of 724 major ar^putations done in his
clinic, and concludes as follows : The medio-tarsal amputations have
increased in number and gained in favour against Syme’s in the amputa-
tions in the lower third of the leg. As little as possible should be
removed except in the upper third of the leg ; it is better to amputate
at the knee-joint than in this region.

For the forearm, antero-posterior flaps with the posterior one-quarter
longer, are to be preferred ; in amputations of the arm, a circular or
modified circular incision ; at the shoulder-joint also antero-posterior
flaps are preferred. The anterior flap includes the greater part of the

NEW TREATMENT

AN>CIVilA IN CHILDREN

deltoid muscle, and is longer than the posterior one. Mediotarsal and
tarsal amputations are preferred whenever practicable when amputa"
tion of the foot is required. It is especially necessary to obtain adequate
flaps, and to cut the anterior tendons long enough to be secured
by sutures to the posterior flap when forming the stump. Low down
in the leg antero-posterior flaps are preferred, but not the Teale or any
extraordinarily long anterior-flap method. In other parts of the leg
lateral flaps seem best. At the knee-joint a long anterior is combined
with a short posterior flap ; the patella may be removed or not. In
the thigh, antero-posterior flaps are best, with the anterior one longer.
They are always shaped from without inwards, never by transfixion.

The mortality is 4*56 per cent for single amputations. The impor-
tant factors in lowering the mortality of amputations for injuries are
saving of blood, careful asepsis or antisepsis, and discrimination as to
the time of operation. The blood-pressure is a useful guide ; a systolic
pressure below 80 mm. should contraindicate amputation.

Interscapulo-thoYacic Amputation. — Carson^ reports two successful
cases of this operation, one for epithelioma following an old burn on
the arm, and the other for a small round-celled sarcoma of the humerus.
He used ether by the insufflation method, and injected cocaine into
the large nerve trunks. One patient was out of bed on the fifth day.
Sufficient time has not yet elapsed since the operation to say whether
recurrence will take place or not. He thinks it should be performed
oftener than is reported for injuries of the shoulder, including gunshot
wounds, extreme bone disease of the shoulder and upper arm, all cases
of sarcoma of the arm and shoulder except possibly those of giant-
celled sarcoma limited to the lower two-thirds of the humerus, all
cases of carcinoma involving the upper half of the arm, and some cases
of carcinoma of the breast where the axilla and arm are involved. In
some cases of tuberculous disease it is also indicated.

References. — '^Aun. Surg. 1913, ii, 39 ; Hbid, x, 796.

AN.fflMIA IN CHILDREN. Fvedevick Laugincad, M./)., F.R.C.JK

Tixier^ points out that the features of this condition peculiar to
infants are the frequency and intensity of the myeloid reaction whatever
the degree of anaunia, the rapid and striking fall in the colour index,
and the frequent association of the reactions of the spleen and marrow,
producing a pseudo-leukaemic form of anaemia. A study of the blood-
forming organs shows a condition of exalted activity and exhaustion of
the bone-marrow. Tn some cases the condition of the blood corresponds
to that of the marrow, but in others, notably in hereditary syphilis,
this does not hold true. The form of leucocyte does not always give
precise information as to the cause of the anaemia, though a persistent
increase in mononuclear cells and myelocytes is strongly suggestive
of syphilis.

French physicians have differentiated a type of anaemia characterized
especially by a considerable decrease in the amount of haemoglobin,
which they have termed anSmie pseudo-chlorotique. It is related

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MEDICAL ANNUAL

almost always to defective nmtrition. According to Leuret, haemolysis
plaj^s the leading part in the production of anaemia in infants, and may
be present in every degree, from the rapid cell destruction which occurs
in haemolytic jaundice, to the slight but prolonged haemolysis which
betrays itself by anaemia of varying severity vrith or without spleno-
megaly. Anaemia of pernicious type would appear to be less rare in
infants than has generall3’’ been supposed, and may be secondary to
hereditary syphilis, septicaemia, middle-ear disease (Ribadeau-Dumas
and Poisot), to pyelonephritis (Carpenter), to abdominal tumour
(Ribadeau-Dumas and Camus), to a combination of diseases (Tixier),
or to causes unknown (Cristina).

R. Jemma® describes a peculiar form of anaemia -which is endemic
to the shores of the Mediterranean. It runs a chronic course, and
especially affects infants in the first year of life, being characterized by
fever, anaemia, progressive enlargement of the spleen, and wasting.
It is due to infection by a parasite identical with that which Leishman
and Donovan have discovered in India in patients suffering from kala-
azar, and is generally fatal. As long ago as 1880 Cardarelli named it
infective splenic anaemia of infants. Pianese discovered the pathogenic
agent in 1905, and in 1908 NicoUe obtained a pure culture and inocu-
lated it into a dog. Although there is still considerable difference of
opinion, recent work tends to show that the disease is identical with
kala-azar or tropical splenomegaly. It is transmitted from dogs to
man by fleas, especially affecting children of the poorer classes of from
one to three years of age.

The incubation period is unknown. The onset of the disease often
passes unnoticed, and is characterized by fever and gastro-intestinal
disturbance. When it has developed, the piincipal features are fever,
anaemia, and enlargement of the liver and spleen. Increasing feebleness
and wasting lead to cachexia, or death may intervene before cachexia
has developed. In the later stages, intractable diarrhoea and marked
emaciation • may occur. Death may be due to intercurrent diseases,
such as pneumonia, noma, haemorrhage, oedema of the glottis, nephritis,
or sudden fatal dyspnoea. Jemma examined the blood of fifty-four
cases. The haemoglobin -was always diminished. Usually the red
cells were markedly reduced, whilst anisocytosis, poikilocytosis and
nucleation were rare. Polychromatophilia was common. The colour
index was variable, but usually diminished. Leucopenia was the most
characteristic feature. Lymphocytes were the. white blood-cells in
greatest abundance. There were never leucocytosis or persistent
marked alterations in the red cells, such as are found in other forms of
anaemia in infants.

Czerny® emphasizes the importance of distinguishing between
anaemia and pallor. For pallor to constitute anaemia, it is necessary
for the mucous membranes to be pale as w'ell as the skin, and for
examination of the blood to show a decrease in haemoglobin and in the
number of cells. Pallor of vasomotor origin occurs in nearly all the
gastro-intestinal disorders of children, and is often their first symptom.

NEW TREATMENT

ANAEMIA IN CHILDREN

On the other hand, anaemia so produced is almost confined to the fii’st
two years of life. iVccording to Czerny, insufficient nourishment is not
the cause of the anaemia, but in his experience it has developed exclu-
sively in certain infants fed for a long period entirely on milk. The
reason why some infants fed thus develop anaemia, whilst others do not,
he ascribes to a congenital anomaly. In some cases, pallor and blood
changes are the only signs of anaemia, in others the spleen enlarges.
The connection between obesity and anaemia due to alimentary disturb-
ance is so close, that if the former is not present, grave suspicion should
be entertained of the alimentary origin of the anaemia. Besides
obesity, infants suffering from this form of anaemia develop softness
and flabbiness of the muscles, but growth is not affected.

Treatment. — As Tixier remarks, among therapeutic agents adminis-
tered to stimulate blood-production are Iron, Arsenic, Extracts of
Ductless Glands, X-rays, and the Haematinic Serum of Carnot. For
each form of treatment a certain number of successful cases are claimed,
but it is difficult in a given case to determine which is indicated. Mild
or moderate forms get well under the influence of ordinary remedies.
Treatment directed against haemolysis has met with only a small
measure of success. The attempt to utilize the anti-hasmolytic power
of Cholesterin has only led to transitory results. For the endemic
ansemia resembling kala-azar, Jemma advocates the destruction of
infected dogs and of fleas. The child should be isolated. Therapeutic
measures such as Quinine, Atoxyl, Biniodide of Mercury, and Iodine
have, at present, given only negative results. Salvarsan has been
disappointing. Radiotherapy has also proved useless. Arsenical
Preparations have given the most encouraging results. Splenectomy
is not indicated, for the parasites are found as commonly in other
organs.

For the anaemia due to alimentary causes, Czerny, believing that it is
due to an exclusively milk diet, recommends that treatment should be
devoted to remedying the defect either by adding other forms of food
or by medicines. When these measures fail, milk should be prohibited
altogether. Iron is of no avail if the infant is left on the diet which
caused the anaemia. Improvement often follows if the milk diet is
supplemented by foods rich in iron, such as eggs, fruit, and spinach or
other green vegetables. At the onset, or in mild cases, all that may be
necessary is to reduce the quantity of milk to one-third or one-half,
and supplement it by adding vegetables, gruel, rice, tapioca, or fruit.
In grave cases milk must either be stopped altogether or reduced
to loo or 200 gr. daily. In addition, meat may be given twice
daily. Under this regime he states that the most severe cases of
anaemia may be cured in three or four months. [The value of meat
juice and meat-juice preparations should not be forgotten in these
cases.]

Splenic anaemia of the adult type is little benefited by medical
measures, and for patients suffering from this condition Splenectomy
would appear to offer the greatest hope of cure. Thus Burghard and

ANEMIA IN CHILDREN IjS MEDICAL ANNUAL

Sutherland'^ record t\v(.> cases of the familial type successfully treated
in this One was a girl, aged 13, the other also a girl, aged dj.

The general condition and state of the blood in both became normal,
and they are now in good health, the former seven years and the latter
three years after operation. Makins® and Hutchinson® have each
recorded a successful case. Probably the youngest child cured by this
measure is a girl, aged 5, operated upon in 1895 b^’’ Blan d- Sutton, ’
who mentions that she has become a health^L attractive woman, and
now works as a compositor.

References — '^Py^sse Med. 1912, 841; ^Ibid. 842; ^Proc. Roy.

Soc. Med. 1911, iv (Clin. Sec.)^ 5S-70 ; ^Ibid. 1913 (Siirg. Sect), 240; ^Ihid.
236 ; '^Ibid. 237.

ANiEMIA, PERNICIOUS. {See also Splenomegaly.)

Herbert French, M.D,, F.R.C.P.

Etiology. — Bartlett^ reports a remarkable instance in which, out
of a family of eight persons, four deaths from pernicious anaemia
occurred within thirty years ; all the patients lived all their lives on
one farm. The diagnoses were confirmed by autopsy, and every effort
was made to exclude the possibility of parasitic infection. Examples
of family pernicious anaemia have been recorded previously, but they
are rare. In one of Bartlett’s cases, in which the Wassermann reaction
was negative, an intravenous injection of salvarsan was given without
any benefit.

Several observers have stated that they have found a lipoid substance
in extracts of the gastric mucosa of pernicious anaemia cases, having very
much greater haemolytic powers than have similar extracts of other
human stomachs. Results of this kind have been quoted extensively
as supporting the view that the toxin responsible for the blood-
destruction which produces pernicious anaemia is produced in the walls
of the stomach. Ewald and Friedberger,® ho'wever, have made careful
extracts from the stomachs of two fatal cases, and find that these have
no haemolytic action on either whole blood or on red blood-corpuscles,
either with or without the addition of complement.

Carcinoma of Bone-marrow. — Carcinoma often produces a facies and
general appearance that suggests pernicious anaemia, but in nearly all
such the colour index is low instead of high, so that by means of blood-
counts pernicious anaemia can be either diagnosed or excluded. An
important exception to this rule arises, however, when carcinoma leads
to metastases in the bone-marrow ; for the blood picture may then
simulate that of pernicious anaemia very closely. Harrington and
Kennedy® record tw^o cases in point. The first was a woman, 64 years
of age, w^hose symptoms pointed somewhat indefinitely to cancer of the
stomach. Bone pains w^ere marked. She had a severe anaemia of a
peculiar type, showing marked diminution of the red cells, high colour
index, granular basophilia, polychromatophilia, slight poikilocytosis,
megalocytosis, a relative lymphocytosis, and the constant presence of
numerous myelocytes and erythroblasts, the majority of which were
megalobiasts. Post mortem a carcinoma of the stomach was found,

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AN/EMIA, PERNICIOUS

mth metastases involving the marrow of several bones. In the second
case, the diagnosis of carcinoma of the stomach was obvious, but the
appearance was ver^^ similar to that of pernicious anemia, and the
blood showed a liigh colour -index, pronounced anaemia, megalocytosis,
slight polychromatophilia, at first a relative lymphocytosis, a moderate
number of myelocytes, and a few normoblasts and megaloblasts.
From the similarity of the blood picture to that of their first case, they
diagnosed secondary metastases in the bone-marrow, and this was
confirmed post mortem. A prominent feature of both these cases was
pain all over the body, but particularly in the long bones. The authors
conclude that in any case of grave ansemia, the presence of pains and
tenderness of the bones should always arouse suspicion of carcinoma
of the bone-marrow. If the blood on examination shows characters
suggestive of pernicious anaemia, but wdtli an excess of erythroblasts
and myelocytes, the diagnosis of metastases in the bone-marrow
highly probable.

Symptoms. — ^IMichell Clarke* draws attention to certain difierences
in the course of pernicious anaemia in persons over fifty » as compared
with the course of the malady in younger persons. It tends to be more
chronic in the old ; to have a less pronounced degree of anaemia when
it is first recognized ; to show less tendency to the remarkable ups and
downs of younger persons ; fewer haemorrhages other than retinal ;
whilst blood-films, though presenting abundance of macrocytes, tend
to be remarkably free from megaloblasts and normoblasts except at
the very end. He treated two of the eight cases with salvarsan ; one
benefited little, if at all ; the other improved rapidly and enormously.

The yellow tinge of the skin in pernicious ansemia often leads to a
suspicion that the patient is jaundiced, but true jaundice, with yellow-
ness of the conjunctivse, is distinctly rare in this malady ; nevertheless
Poynton and Pedler^ draw attention to the fact that it may occur, and
report one case in full. There was no bile pigment in the urine, the
condition being of the type known as acholuric jaundice. Both arsenic
and neo-salvarsan \vere tried in their patient, but neither seemed to
exert any beneficial effect. Their case Avas discussed before the Medical
Society of London, and notes of three precisely similar cases were
contributed by Box and Taylor.®

Treatment. — Opinions are still divided as to the value of Salvarsan
in the treatment of pernicious ansemia, some observers believing that
it does harm instead of good. Apparently it is impossible to forecast
which cases will do well with it and which badly ; but that it often
relieves materially when other remedies have failed seems certain.
Byrom BramwelP gives the results in ii cases : 4 were apparently
cured, though naturally they may relapse again ; in 2 there was
striking improvement ; in i a marked temporary benefit but subse-
quent relapse and death ; in 2 there was no improvement ; i
was still under treatment; and i was beginning to improve, but
developed bronchopneumonia and died. He gives the salvarsan
intramuscularly in doses of about 0*3 gram, and at intervals of from

AN/EMIA, PERNICIOUS

loo

MEDICAL ANNUAL

a week to a month. The number of doses given in each case varied'
from one to four. Few authorities hold that syphilis is a cause of true
pei'nicious anemia, but the syphilitic taint is so common that it would
be surprising if it did not coincide with pernicious anaemia sometimes.
Weichsel® records and quotes typical cases in point.

Boggs® records four cases treated by salvarsan ; all showed a favour-
able reaction to this treatment as regards the regeneration of the blood
and the relief of symptoms. One was a very remarkable apparent
cure of a patient in his fifth relapse, who had become quite unresponsive
to Fowler’s solution. In all, the Wassermann reaction was negative.

Hobhouse^® also records a case of remarkable benefit from the use of
salvarsan in pernicious anaemia. His patient was extremely ill, in a
relapse of the disease wdiich had previously responded to arsenic ;
O’ 3 gram salvarsan was given intramuscularly on May 31 ; improve-
ment was obvious within three days, but there was a good deal of pain
at the site of injection for over a week. A second similar dose was given
on June 14th, and it w’as followed by a severe reaction. Hobhouse
gives it as his opinion that a second injection should always be postponed
as long as there is still progressive improvement from the first. That
salvarsan fails to benefit some cases, however, is only to be expected ;
Byrom Bramwell points this out, and others have found the same.
Maynard, for instance, records a case in which though there was
slight increase in the i*ed cells after a first injection of 0*3 gram salvarsan
given intramuscularl}^' on October 13, a definite decrease followed
a second injection on October 29, and there was no subsequent
improvement.

Amongst the newer remedies applicable to the treatment of pernicious
anaemia, Thorium-;tr is likely to attract much attention. Thorium itself
is one of the radio-active metals ; various products and emanations
are obtainable from it ; thorium-A' is one of these, prepared by submit-
ting a solution of sodium chloride, 1-3000, to the action of radio-
thorium. It may be given therapeutically either through the mouth
or by injection into a vein ; its strength can be measured in Mache
units by means of a special electroscope; its " life” is five and a
quarter days. A succinct account of it, and of its use in pernicious
anaemia, is given by F. E. Park.^®

The observed fact that after twenty-four hours the greater part of
the thorium-.r that had been given to dogs could be recovered from
the red marrow of the bones, directed the attention of investigators to
its action upon the blood. Then it was found that there was a remark-
able stimulation exercised upon the red-cell formation. This discover}^
was eventually made use of by A. Bickel, professor of internal medicine
at the University of Berlin.

Up to September, 1912, there had been 9 cases treated by this
method. Three of these showed no effect, and probably were cases of
so-called secondary pernicious anaemia, for in such cases it has been
observed that thorium-A has no effect. The other 6 cases responded
in the same manner as did that of Bickel’s, and are apparently cured.

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AN>EIVI1A, PERNICIOUS

Park's case, in a man of forty, is described as follows : —

“ The previous history up to the time of his present disease is negative,
save for a severe attack of yellow fever in 1888. He fully recovered
from this, and for many years has led an athletic life. While teaching
at college in 1906, his health began to fail, and in May, 1897, he
consulted an eminent hasmatologist in the University of Michigan, and
was told that he had pernicious anaemia. He improved under arsenic
and went along for nearly a year, when he had another relapse. Again
the arsenic was of service, although he was longer getting back on to
his feet ; in fact he did not get entirely back this time, but kept along
fairly well until in 1908 he had a very severe relapse. After about four
months he got about again, and from that time, save for an attack of
pneumonia in 1909, he did veiy^ well up to the early fall of 1912.

" About this time a bad relapse started, and although the old
remedies that had formerly checked the progress of such an attack were
faithfully used, he steadily failed, until things began to look very
serious. At this time I obtained my thorium and began treatment
with it. During the first three weeks I combined with it an electric
treatment of the long bones and solar plexus, which had given such
good results in the treatment of the case since 1908, that I was very
loth to discontinue it. He continued to fail steadily, and it occurred
to me that possibly the electricity was in some way rendering inert
the thorium emanations, so this was stopped. At once he began to
gain in a very decided manner. His condition at that time was as
follows : (Edema of all the dependent parts, dyspnoea upon the slightest
exertion, poor appetite and feeble digestion, and a blood count of
1,200,000 red corpuscles. In just four weeks from that time he was
walking about town as vigorous as ever ; oedema entirely gone, fine
appetite and digestion, and a blood count of 4,800,000 red cells. One
week later the count went to 5,280,000; the blood picture was normal,
and the patient volunteered the statement that lie had not: felt so well
for seven years. As a test of his heart action he recently climbed a,
long hill, with a snowstorm in progress, without getting out of breath.

“ Of course many years must elapse before we can positively say
that such a case is entirely cured ; but the return to normal of the
cells, in shape as well as quantity, leads me to feel very optimistic. In
his case the reined}^ was given almost entirely by the vein, 20,000 M.
units being injected into the median basilic every other day witJi an
all-glass S3^ringe and a 27-gauge needle. No irritation was felt. At
first, a few injections were made into the muscles, but as this caused
considerable soreness it was discontinued. A recent communication
from Dr. Bickel advises me that in his opinion it is best to give an
intravenous dose of 50,000 M. units once every four days until three
have been given, and then to continue the treatment "with a daily
portion by the mouth of 20,000 units, one-third to be taken after each
meal." (See also under Thorium.)

Brieger^® speaks highly of the use of Pancreatin in addition to
Arsenic in the treatment of pernicious anaemia. He gives the arsenic

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in the form of Fowler’s solution thrice daily after food, starting with
two-drop doses and rising steadily to eight-drop doses ; and he gives
the pancreatin — “ as much as lies on the point of a knife ” — three
times a day before meals. He reports 3 cases so treated ; all im-
proved rapidly for the time : 2 died later in a relapse, but i is still
well, three years after the original treatment. He holds that the
pancreatin definitely assists the arsenic in the cure, even though the
latter may not be lasting.

References. — '^Jouv. Amer. Med. Assoc. 1913, i, 176; Weut. med. Woch.
1913, 1293 ; ^Lancet, 1913, i, 376; ^Bvist. Med.-Chir. Jour. 1913, June, 97 ;
^Clin. Jour. 1913, Feb. 273 ; ^Ibid. ; ’’Brit. Med. Jour. 1913, i, 1093 \ ^Munch.
med. Woch. 1913, i, 1143 ; ^Johns Hop. Hosp. Bull. 1913, 322 ; ^^Brit.
Med. Jour. 1912, ii, 1659 ; ^'^Ibid. 1913, i, 71 ; ^^Med. Rec. 1913, i, 429 ;
^^Deiit. med. Woch. 1913, 2154.

SPLENIC. {See Splenomegaly.)

ANEMIC SUBJECTS, OPERATIONS ON.

Victor Bonney, iCl.S., M.D., B.Sc., F.R.C.S.
Bryden Glendining, M.S., F.R.C.S.

Cullen^ has published the after-results of gynaecological operations
on 170 patients with a haemoglobin percentage of 40 or less. He finds
that as a rule patients with a relatively low percentage stand pelvic or
abdominal operations well, but in cases of carcinoma of the uterine
cervix or body the danger is increased. He regards transfusion as the
best method of ti eating the anaemia, and says it should be performed
before operation in such cases. He points out that great care is
necessary in their after-treatment, especially in avoiding the use of
strong purgatives.

Reference. — ^Surg. Gyn. and Obst. 1913. h. 276.

, ANAESTHETICS. /. Bhtmfeld, M.D.

Inhalation Anmsthesia. — ^The use of Nitrous Oxide with oxygen for
major surgery has been much under discussion recently. The conten-
tion of Crile ^that, for avoidance of shock, nitrous oxide is far superior
even to ether, is partly, no doubt, responsible for the awakened desire
to use it in cases where hitherto it has been considered inefficient. The
combined use of preliminary alkaloids has also widened the field within
which satisfactory?’ results may be obtained by so comparatively weak
an agent. The absence of all toxic efiects from its use renders it, of
course, far superior, as regards immediate and remote after-effects, to
the poisonous anaesthetics. It is their greater efficiency, particularly
from the point of view of muscular relaxation, that has hitherto kept
nitrous oxide out of the field. Some of the extreme advocates of the
latter are prepared to maintain that even in the matter of muscular
relaxation this agent can always be made to give all that can be required.
Such, however, is not the opinion of Teter,^ whose experience with
nitrous oxide in major surgery is very large indeed. He writes :

Muscular tone is maintained to a much greater extent than when
ether or chloroform is used, it being impossible to obtain the same

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degree of flaccidity of the musculature that can safely be procured
with the more powerful anaesthetic agents.”

In consequence of this, and other properties of nitrous oxide, it is,
he says, necessary to utilize every known scientific principle that will
enhance the efficiency of the gas in order to make it practical as an
anaesthetic. These principles he states to be : (i) The use of pre-
anaesthetic narcotics, (2) The use of oxygen, (3) The even flow of both
nitrous oxide and oxygen, (4) Warm gases, (5) Re-breathing, (6) Positive
pressure. It will readily be understood that to meet these requirements
apparatus of considerable complexity and bulk is necessary, and that
is, indeed, the chief practical obstacle to the method under discussion.
When, however, the advantages offered are great and important, as
they undoubtedly are in certain cases, the mere question of incon-
venience and labour must be waived. Anaesthesia lasting one hour
requires on the average 100 gallons of nitrous oxide and 20 gallons of
oxygen.

Teter reprds it as an established fact that all anaesthetics are safer
when administered warmed. He believes, with Gwathmey, that when
warm they are increased in value as regards life without a decrease in
their anaesthetic effects. In forty cases, he found that if nitrous oxide
was at 90° F., the induction period averaged 30 seconds ; when the
gas was at 42° F., the time necessary for inducing anaesthesia was
52 seconds. Many of the patients inhaling the warm gas were uncon-
scious after two to six breaths ; most of those taking the cold vapour
required ten or even twenty inhalations to abolish consciousness.

As regards re-breathing, Teter founds his practice upon the principle
laid down by Yandell Henderson in his well-known work upon acapnia,
that carbon dioxide should never be used in greater concentration
than 5 or 6 per cent Teter regulates his re-breathing in such a way
that the percentage of CO^ is from 5 to 9*5 per cent. Tie has arrived
at these figures by careful analysis of the contents of bags subjected to
re-breathing. Positive intrapulmonary pressure may be used with
nitrous oxide to the extent of 6 to 8 mm. Fig.

Teter has some interesting remarks upon the limitations of his
method, and upon the necessity for using some Ether in order to secure
the requisite relaxation. Fie points out that the number of times
when such additional help is required, depends only partly on the
anaesthetist, and partly also upon the operator. When the anaesthetist
is familiar with the surgeon's methods, Teter thinlvS that ether is
necessary in some 5 to S per cent of the cases ; with strange surgeons
the figure is more likely to be 20 to 25 per cent.

Nitrous oxide is not ideal in the case of strong vigoi'ous patients, those
addicted to drugs, or those who are highly nervous, excitable, appre-
hensive, or sensitive. It is in such cases as these that the use of pre-
anaesthetic narcotics is of service. Still further help is to be gained,
according to those who practise it, by Crile's method of combining
the use of Local Analgesics with that of the general anaesthetic. In
addition, Morphia and Scopolamine are used beforehand, and the entire

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lO^

process Crile describes as anoci-association,'''^ meaning thereby the
total exclusion of noxious influences. The method is a logical outcome
of the kinetic theory of shock,® according to which shock is only to be
prevented by the blocking off from the central nervous system of
every kind of trauma, whether physical or psychical ; and Crile has
endeavoured to show that psychical trauma, such as emotion before
operation, is morphologically represented by changes in the brain- cells.
The local analgesic is applied in the form of infiltrations of successi\'e
layers of tissue from the skin onwards, Novocain -25 per cent, and -5
per cent of Quinine and Urea Hydrochloride being the agents employed.
The latter has for its special aim the prevention of after-pain.

Nitrous oxide and oxygen in major surgery has been advocated in
Great Britain by several writers during the past year,*^ and from the
patient’s point of view there is undoubtedly often immense advantage
in restricting ansesthetics to this non-poisonous agent at the same
time, its administration in major surgery requires more experience
than that of any other aneesthetic, and fatalities occur in the hands
of the unaccustomed.®

In an article upon the chemistry of inhalation anaesthetics, Basker-
ville states that nitrous oxide should contain at least 95 per cent
and no solids, liquids, combustible organic matter, chlorine, or other
oxides of nitrogen. If CO 3 is present, the percentage should be known.

The relation of shock to blood-pressure is discussed by Bloodgood,^
who asserts that under nitrous oxide with local analgesics the blood-
pressure remains more or less uniform, and that this method of
anaesthesia reduces mortality in all operations in which shock is the
fatal agent.

Intratracheal Anaesthesia . — ^This method, originated by Meltzer, of
New York, as the result of laboratory experiments, is now being
extensively tried in this country. It presents obvious advantages in
certain cases, those particularly which involve bleeding that may affect
the air-passages ; for the continuous outgoing stream of air at the
glottis entirely prevents the risk of aspiration of blood or any other
foreign bod^^ such as pus or mucus. It is probable that further
experience will allow of simplification of the, at present, rather com-
plicated apparatus required. Such simplification has to some extent
taken place already, and the machines of Shipway and of Kelly {Figs.
3, 4) are less cumbrous than the original form devised and used by
Elsberg. The practical points in the management of this method are
thus described by Kelly® : The patient is anaesthetized in the ordinary
way by ether, and must be well under. This is a very important point,
for if the anaesthesia is insufficient it will be difficult to pass the tracheal
tube, and trouble may be experienced owing to glottic spasm. With
the head well over the end of the table a direct laryngoscope is passed.
No attempt should be made to pass the catheter without seeing the
glottis. To try to pass it blindly through an introducer is less satis-
factory than this simple procedure under direct vision. The tracheal
catheter used is the ordinary coude with two side-openings. The beak

NKW TREATMENT

AN>!ESTHETICS

105

of the instrument is ver^?’ useful in directing it into the glottis. It is
passed down to the bifurcation, i.e., about 26 cm. from the incisor
teeth. The current of air is now directed into the catheter. At first

3 — Kelly’s apparatus for intratracheal anaesthesia. 'I’he niodiliecl apparatus.

there is some spasm of the glottis, and the pressure inside the trachea is
raised by expiratory efforts. This is shown by the fact that the safety

Fig. 4.— Kelly’s apparatus for intratracheal aniesthe.sia. The motor and blow er.

valve begins to bubble. Full ether is now turned on, and the current
interrupted by opening the third tap every few seconds. The spasm
will soon pass off. The percentage of ether is now lessened and the

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pressure lowered, until the patient passes dn to a state of regular but
feeble respiratory movements. An average pressure of 20 mm. Hg
will suffice for all general surgical work with the chest unopened. For
the remainder of the anaesthesia one has merely to vary the percentage
of ether according to the patient's condition, and occasionally to
interrupt the current and allow the pressure to fall to zero. After the
operation is over, pure air is passed for a few minutes and the tube
taken out before the current of air is turned off.

Cotton and Boothby^® furnish a full account of the physiological
principles on which this method is based, and also describe the use
of nitrous oxide and oxygen in this procedure. They conclude that
the method should be chosen for all intrathoracic surgery and in
extensive operations about the head, neck, and mouth, and that a safety
valve, by means of which the intrathoracic pressure cannot exceed
15 mm. Hg should always be part of the apparatus. They also make
the statement which, if borne out, will have great effect in simplifying
apparatus, that warming is not necessary ; given a large ether chamber
and 3 ft. of rubber tubing leading from it, then the ether-laden air
will be about the room temperature by the time it reaches the lungs.

Anaesthesia by pharyngeal insufflation is recommended by Pineo,^^ and
his apparatus, a variation of Junker’s familiar instrument, is described.
The warmth of the vapour and its perfectly continuous administration
are the points of advantage claimed over the ordinary method, as well
as the removal of the anaesthetist's hands from the field of operation
in head and neck cases.

Chloroform. — A valuable contribution to the elucidation of death
during chloroform ancesihesia is made by Goodman Levy,^^ who shows
reason to believe that ventricular fibrillation is the essential cause of
chloroform death, and adduces arguments to show that intermittent
administration and too light an anaesthesia are common causes of
tachycardia, which may be the prelude to irrecoverable fibrillation of
ventricles. The same author has described the danger of the association
of light chloroform anaesthesia with adrenalin injection, and a clinical
example of this fatal combination is recorded by Depree.^^ Levy’s
general conclusions are that the mammalian heart, when under
the influence of chloroform, is in an irritable ” condition. This
irritability is raised under conditions of light anaesthesia and lowered
under deep anaesthesia. Abnormal ventricular beats are evoked in a
heart under chloroform by conditions which stimulate it, or by equiva-
lent conditions which remove or reduce depressing influences. Under
conditions of light chloroform anaesthesia the ventricular iiTegularities
arising from cardiac stimulation may terminate in ventricular fibrilla-
tion and death. Stimulation of the heart may be effected : (i) As a
reflex from sensory excitation ; (2) As a result of an intermittent

administration of the anaesthetic ; (3) As a result of the state of nervous
excitement accompanied by struggling, induced by chloroform in the
earlier stages of its administration. Ventricular fibrillation is a cause
of death under chloroform, probably the only cause of any moment.
It can be prevented by steadily maintaining a full degree of anaesthesia .

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AW>ESTHETICS

Dudley Buxton^** gives a full account of the dosimetnc method of
administering chloroform, describing its principles and the way in
which these are put into practice.

The secretion or inactivity of the lacrymal gland has not been
taken into account hitherto as an indication of lightness or depth of
anaesthesia. The value of the observation of the tear-drops in the
eye from this point of view is discussed by Rutherford. He maintains
that in the third stage the lacrymal secretion ceases at the same time
that the earliest reflexes disappear, and that this cessation usually
precedes the abolition of the comeal I'efiex by a very short interval.
When the “ canthal ” tear is present, the corneal reflex should be
obtainable, and the amount of the anaesthetic is as much as is com-
patible with successful anaesthesia.

In an article^® upon the danger and prevention of severe cardiac
strain during anaesthesia, the authors comment upon, and give instances
of, the possible harm of the Trendelenberg position in certain cases.
They find that any failure of respiration is made much more dangerous
hy the head-down position, and give cases and experiments bearing
upon their opinion.

At the British Medical Association meeting,^’ the question was
discussed of the desirability of anaesthetists examining their patients
beforehand. A consensus of opinion expressed by various speakers
showed the advantage of such a proceeding and the disadvantages to
the patient of its omission.

Intravenous ancssthesia seems to be establishing itself as a valuable
method for certain selected cases. Ether alone does not appear always
to be effective, unless in dangerously strong solution, and cases are
reported^® of its use in combination with Paraldehyde and Isopral.
No large amount of experience with these drugs is as yet available from
which to draw conclusions. The intravenous employment of Hedonal
in the case of children is well discussed by Barrington-Ward,^® who
regards the method as equal in immediate danger with the giving of
chloroform, but unsurpassed in its freedom from various after-effects.
The whole question of hedonal anaesthesia was ventilated in a discus-
sion at the Medical Society of London,’-^® as well as at the Aiicesthetic
Section of the Royal Society of Medicine.^®

Anesthesia paralysis, which is always an example of pressure palsy,
is the subject of a paper by Molinari.21 The positions, and the kind of
patient, in whom it is most likely to be brought about, are arrived at
from a considerable series of cases.

Spinal analgesia continues to be favourably I'eported upon by those
who use it largely. Major Houghton®® reports 400 cases without any
case of failure to anaesthetize, or of consequences causing anxiety.
Bambridge®® writes on a basis of 1065 cases, in which there was one
death, one case of partial paralysis with complete recovery, and one
case of failure. He had two cases with Alypin, in which there was
considerable respiratory depression, and one case of idiosyncrasy in
which, after several attempts by spinal and local injection, the analgesia

AN>€STHETICS lo8 MEDICAL ANNUAL

was almost nil. Freeman Allen^^ reports improved results with
increased experience. A variety of this method, extradural
anaesthesia,** is described in a preliminary report by Lynch.^^ It has
very strictly limited application. Nicolich^® prefers spinal analgesia
to all other methods for urino-genitary operations ; the maximum dose
of Stovaine that he uses is 5 cgrams for operations upon the kidney,
3 cgrams for operation upon the bladder and prostate.

Schlempert^^ describes sacral ancesthesia, i.e., a combination of extra-
dural ana3sthesia with preliminary Dammerschlaf ” (hypodermic injec-
tion of narcotic alkaloids) , as used at the Freiburg Frauenklinik. Here
it is preferred for all cases except short operations, and for those upon
women who have defects of the vascular system or who are very fat.

Local and Regio 7 ial Ancesthesia, — ^The various forms of local analgesia
by infiltration, by endo- and peri-neural injection, and by venous
infiltration, have a wide field of usefulness. The fact that their use
involves a considerable expenditure of extra time accounts probably
for the comparatively few occasions on which surgeons avail themselves
of them. Their use in the reduction of fractures and dislocations is
drawn attention to by Braun, who has made so extensive a study of
local anaesthesia of all kinds.^o Harris, of Chicago, contributes an
article upon nerve-blocking, or, as it is more often called, regional
anaesthesia, in which he lays special stress upon its advantage from
the point of view of shock prevention ; and from Bier’s clinic comes an
account of direct anaesthesia of the smaller cutaneous veins in opera-
tions on the hands and feet.®^ Difficulty in swallowing, and trismus
following upon mandibular local analgesia, are alluded to in another
German contribution. ^2 Felix Rood^^ gives an excellent and practical
account of regional analgesia, and in the same journal will be found
an account of supraclavicular anaesthetization of the brachial plexus.

References. — ^Jour. Amer. Med. Assoc. 1912. ii, 1849 ; ^Snrg. Gyti.
and Obst. 1913, i. 627 ; ^Lancet, 1913. il 7 ; ^Pract. 1913. ii 267 ; ^Edin,
Med. Jour. 1912, ii, 517 ; ^Jour. Amer. Med. Assoc. 1912, ii, 187 ; Ubid. 1S37 ;
\Surg. Gyn. and Ohsi. {abstract) 1913, ii, 3 ; Jour. Surg. 1913, 90 ;

Siirg. 1913, i, 43 ; '^'^Jour. Amer. Med. Assoc. 1912, ii, 1S62 ; ^^Heavt, 4 ;
^^Brii. Med. Jour. 1913, i, 879 ; ^^Lancet, 1913, ii, 464 ; Med. Jour.

1913, i, 1313 : '^^Joitr. Amer. Med. Assoc. 1913. i 1272 ; ’^"^Brit, Med. Jour.

1912, ii, 612 ; "^^Surg. Gyn. and Obst. 1913, i, 475 ; ^^Brii. Jour. Child. Dis.
I9i3» 17 ^ “^Lancet, 1912, ii, 1297 ; '^^Surg. Gyn. and Obst. 1913, i, 475 ;
-Mancet, 1912, ii, 1008; ^^Jour. Amer. Med. Assoc. 1912, ii. 1S55; ^^Ibid.ih^i\
^^Med. Rec. 1913, i, 235 ; ^^Surg. Gyn. and Obst. 1913, i, 2 ; ^"^Ibid, i, 48S ;
'^^Brit. Med. Jour. 1913, ii, 69 ; -^Deut. med. Woch. 1913, ii 24 ; ^^Jouv. Amer.
Med. Assoc. 1913, i, 1040 ; '’^^Arch. f. klin. Chiv. 1912, xeix, 983 ; ^^Deut.
Zahn. in Vortr. 1913, xxviii, 31 ; ^^Brit. Med. Jour. 1912, li, 1701 ; ^^Ihid,

1913. i- 38 S-

ANEURYSM, INTRATHORACIC. Carey Coombs, M.D., M.R.C.P.

De Havilland Hall’s Lumleian Lectures^ summarize for us the
modern attitude tow-ards this malady. Some of his chief points follow.

Etiology. — T wo factors are necessary : arterial disease and over-
strain. To the first, syphilis contributes chiefly ; Winteriiitz’^ histo-
logical observations led him to attribute this, not so much to medial.

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ANEURYSM, INTRATHORACIC

fibrosis, as to gummatous softening of the adventitia, a view which
furnishes additional reason for active antisyphilitic treatment of
aortic aneurysm. That overstrain is important is proved by the
greater incidence of aneurysm in males, in the decades of stress (35-55),
and in districts where heavy physical strain is the common lot.

Dissecting aneurysm is ascribed bj^ Shennan a.nd Pirie® to primary
medial degeneration, with splitting of its elastic fibres, bulging of the
intima into the gap thus produced, and rupture of the blood-current
through the latter into the media, which is split up longitudinally.

Symptoms.— Hall treats of these under seven headings. Pain may
be anginal, neuralgic, or due to pressure ; even large, eroding aneurysms
may, however, cause no pain at all. Respiratory symptoms include
two varieties of dyspnoea : the paroxysms referred by this writer to
compression of the recurrent laryngeal nerves or the vagi, and steadily
increasing shortness of breath arising from gradual compression of
the pulmonary tissues. Pressure on the trachea and pleuial eifusion
are other occasional causes of the dyspnoea, which in the former case
may be paroxysmal and associated with inspiratory-expiratory stridor.
A hard brassy cough is of the utmost importance in suggesting the
possible existence of aneurysm. Haemoptysis may occur early ; it is
sometimes due to a direct leakage into the tubes, sometimes to pressure
on the substance of the lung, sometimes to the passive hyperaemia of
cardiac disease. Hampeln,^ waiting at length in regard to the hcemo-
ptysis of aneurysm, points out that bleeding of the sac into the air-
passages may be gradual or sudden ; that gradual haemorrhage often
foreshadows a sudden outburst ; and that this prodromal leakage
lasts longer if it is the lung itself that is implicated, while it is briefer
in ulcerations into the trachea or bronchi.

Laryngeal symptoms are very common. Hall’s private case-books
furnished twenty- two examples of recurrent laryngeal palsy in thirty-
five patients with aortic aneurysm, nineteen of the left cord only, two
of the right, one bilateral. This sign is of value, since it locates the
aneurysm in the transverse or descending part of the arch. Cardiac
symptoms, apart from those of angina, aortic incompetence (if this
coincide with the aneurysm), and intrapericardial rupture, are singularly
inconspicuous. Dysphagia due to oesophageal compression is of
importance, since if this cause of the symptom be forgotten, an
oesophageal bougie may be passed, wdth disastrous effect. Hall thinks
dysphagia may sometimes be caused by reflex spasm of the pharynx.
Paraplegia is an occasional consequence of vertebral erosion. Ambng
general symptoms he mentions wasting, and an attitude which he
thinks characteristic : the man sits up in bed with the knees draw^n
up, arms forw^ard, shoulders slightly raised, and the head bent forward.

Diagnosis. — Hall insists on the importance of an exhaustive
physical examination, and alludes in particular to some of the pressure
signs. Comparison of the radial pulses may show complete absence
of one of them, inequality as detected by the finger or the sphygmo-
manometer, difference in the character of the sphygmograms, or

ANEURYSM, INTRATHORACIC

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delay in pulse at one or other wrist. The inequalities are apt to
become more definite if the patient be told first to inspire deeply
and then to expire fully and slowly. Mackinnon's® systematic measure-
ments prove that in aneurysm the blood-pressure is usually about
normal ; that in 65 per cent there is asymmetry, and that in 30 per
cent the difference between the pressure on the two sides is so
marked as to be of diagnostic value.

Hall speaks in the highest terms of the value of shiagrapliy in
diagnosis. He points out that every patient suspected of harbouring
an aneurysm within his chest should be examined from behind and
from before, as well as in the right anterior oblique position, with the
fluorescent screen. The only aneuiy^sm that can elude detection by

this means is the small sac

within the concavity of the
arch. The method is not
only valuable in the early
detection of the presence
of aneurysm, but also in
proving its absence in -sus-
picious cases.

Letulle® adds a word of
caution founded on experi-
ence of a case which he
relates, to the effect that
the absence of pulsation
in an intrathoracic shadow
does not necessarily prove
that it is not due to an

ABODE
Fi^, 5. — A, Clear area corresponding to right lung.
B, Shadow of vertebiai column. C. Clear middle space.
D, Shadow of normal heart and aorta. E. Clear area
corresponding to .eft lung; ' dilated aorta;

small commencing aneurysm ; — — shows

in the upper jpart, larger aneurysm ; lower part, position
of dilated auricle. (From De Havilland Halts Lumlcian
Lectures^ after Holzhiecht,

aneurysm, for if the sac be
filled with solidified clot it
may fail to pulsate visibly
on the fluorescent screen,
and may for that reason be
mistaken for a new growth.

Fig. 5 shows diagrammatic-

ally what is seen with the screen when the patient is examined in
the right anterior oblique position.

Laryngeal palsy is of great importance in diagnosis, but it may
also be produced by the pressure of the dilated left auricle in mitral
stenosis and by new growth.

Course. — Hall’s figures indicate that " the duration of life after

the recognition of an intrathoracic aneurysm is usually limited to
less than four years, though in very exceptional cases life may be
prolonged for six or seven years.” Cases are on record of fifteen
years* duration from onset of symptoms. Rupture terminates about
40 per cent of the cases, and is particularly frequent in aneurysms
arising from the transverse and descending portions. It occurs most
often into the left pleural cavit)?-. Cardiac failure, cerebral embolism.

NEW TREATMENT

III ANEURYSM, INTRATHORACIC

pulmonary disease, and intercurrent infections, are other modes of
terminations.

Treatment. — J. A. C. Mace wen ^ records a case which he describes as
one of aortic aneurysm (though the clinical evidence forming a basis
for this diagnosis is not stated fully), in which he introduced a needle
into the aorta on several occasions, scratched its posterior wall, and
thereby produced a deposit of white clot, with marked amelioration of
symptoms. This plan, introduced by Sir William Macewen in 1890,
has not been applied in many instances, but its results have been so
far encouraging as to warrant a further trial, which is more than can
be said for the other surgical devices urhich have been employed.

Of non -surgical plans Hall lays most stress on the method originated
by Tufnell, whose instructions ran as follows : “ Place the patient at
once upon the minimum diet, and forbid even the slightest movement
which can be avoided. The room in which he lies must be as quiet
and secluded as possible. No treatihent by drugs is to be attempted
at the same time. Listen to no complaints of thirst so long as the
pulse and temperature are normal, or nearly so, and the whole allowance
of solid food is consumed. The diet, under ordinary circumstances,
must be confined to three meals served at regular intervals, and
restricted to the following in kind and amount —viz. : For breakfast,
2 oz. of white bread and butter, with 2 oz. of cocoa or milk. For
dinner, 3 oz. of broiled or boiled meat, with 3 oz. of potatoes or bread,
and 4 oz. of water or light claret. For supper, 2 oz. of bread and
butter, and 2 oz. of milk or tea, making in the aggi*egate 10 oz. of
solid and 8 oz. of fluid food in the twentj^-four hours, and no more.
In some iiritable constitutions this restriction in diet will be irksome,
and the patient becomes intolerant and restless. Here, instead of
attempting to persist in the withholding of food, the appetite should
be indulged ^/le satisfying of the patient (so as to keep him tranquil),
but no more” Hall adds that in practice it will be found almost
always necessary to increase the fluid to 12 or even 16 oz. in the
twenty-lour hours; usually 12 oz. of solids are suflicient to satisfy the
patient.

For this treatment patients must be carefully selected ; it is useless
for those whose temperament makes the necessary absolute rest
impossible, also for such as have to return to laborious tasks afterwards.
Alcoholics and persons with aortic incompetence are also disqualified.
The “ aneurysm of physical signs arising from the ascending aorta
is more suitable than that springing from the transverse arch. Sym-
ptoms which call for treatment are pain (Morphine), constipation
(Cascara, Pil. Coloc, c. Hyoscy, or Enemata of Glycerin and Olive Oil),
and sleeplessness (Chloral or Chloralamide, with or without Bromide).
The patient should be allowed to return to a normal posture and
more liberal diet by very slow degrees.

The use of large doses of Potassium Iodide is of indubitable value in
aneurysm ; unfortunately, however, it cannot be applied to those
teceiving the Tufnell treatment, because of the thirst produced by the

ANEURYSM, INTRATHORACIC

112

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drug. Its usefulness is probably due to the fact that aneurysm is so
often an effect of tertiary syphilis {pide supra) ; salvarsan, however, is
contraindicated in cases of aneurysm. The patient taking iodide
may be restricted as to exercise, though not closely limited in diet.
Doses above 20 gr. are not necessary, and they may do harm.

Hall is not optimistic as to the curative value of the treatment
fathered by Lancereaux, of Paris, consisting of intramuscular injections
of Gelatin in saline solution. It involves certain risks, and does not
effect a cure.

References. — '^Lancet, I9i3> i, 803, 869 and 945 ; Johns Hop. Hosp.
Bull. I9i3> 212 ; ^Brit. Med. Jour. 1913, ii, 1287 ; ^Deut. med. Woch. 1913, 831 ;
^Brit. Med. Jour. 1913. it 863 ; ^Presse M6d. 1913. 214 ; ’’Ann. Surg. 1912,
it O75.

ANEURYSMS, SURGERY OF. {See also Aneurysm, Intrathoracic,
and Arteries, Surgery of.) Priestley Leech, M.D., F.R.C.S.

Aneurysm of the Superficial Palmar Arch. — Regnault and Bourrat-
Laconture^ report a case of this disease caused by repeated contusions.
The patient was an artilleryman who had been in the habit of striking
the breech of a cannon with the palm of his hand. The aneurysm was
treated by ligature of the artery at each end of the sac. The authors
recommend excision as the best method of treatment. As a rule, these
aneurysms arise from a wound of the vessels from a knife or other
sharp instrument.

Aneurysm of Abdominal Aorta. — Collins and Braine-HartnelP
publish a case of abdominal aorta treated by means of Colt’s apparatus.
The diagnosis was difficult : the man had been sent into hospital as
a case of acute appendicitis. Laparotomy revealed an aneurysm
springing from the aorta below the origin of the renal artery, and
extending as far as the bifurcation of the aorta. Colt’s trocar was
thrust in, and a cap packing of 150 inches of wire was passed into
the tumour. The patient died six days later. The authors say the
wire did not form a cage as it was supposed to do ; and the kind
used was too stout.

Subclavian and Innominate Aneurysm. — Lothrop,^ of Boston, U.S.A.,
reports a case of bilateral subclavian aneurysm. Out of a series of
120 subclavian aneurysms, in only two instances were the lesions
bilateral. The patient was a man, 49 years old, who had contracted
syphilis twenty-five years previously. The aneurysm of the left
subclavian was excised, and four years later the patient returned \wth
an aneurysm of the right subclavian, and in this case the artery?- was
tied at either end of the sac, which was opened, cleared of clot, and
obliterated after the method of Matas. Convalescence was uneventful.

Jmai,^ of Osaka, reports a case of aneurysm of the innominate artery
successfully treated by extirpation. The patient had previously had
a popliteal aneurysm extirpated. Jmai thinks that this method of
treatment is to be recommended in the early^ stages and where the
vessel wall is not too much diseased.

KEW TREATMENT II3 ANEURYSMS, SURGERY OF

- Aneurysm of the Internal Iliac Artery, — ^IVIacLaren® reports a case
in a woman, aged i8, which came on soon after a severe confinement.
Matas, in Keen’s Surgery,” reports several thousand cases of
aneurysm, but not one of the internal iliac artery ; Ericson, in a large
number, only reports a single case. MacLaren operated, as it was
increasing in size. He made a Pfannenstiel (transverse) incision with
the idea of reaching the deep pelvis more easily, but was disappointed,
as he could not see a small portion of the sac. He followed the common
iliac artery to its point of division, and the posterior iliac was tied by
the sense of touch with heavy catgut. When the ligature was tightened,
pulsation in the tumour entirely disappeared. A year and a half later
the tumour was much harder, with very slight pulsation.

Occlusion of Abdominal and Thoracic Aorta, — Halsted,® of Baltimore,
reports some experiments on occlusion of arteries by bands of fresh
aorta and fascia lata. He had previously applied aluminium bands
to the human aorta four times with promising results ; but experi-
mental work on animals led him to expect that ultimately the metal
bands would cut through the artery. These fears were well founded ;
ah old woman to whose abdominal aorta a metal band was applied,
with cure of her aneurysm, was seized with pain at the end of six weeks
after leaving the hospital, returned to bed, and died next morning from
haemorrhage, the aorta having ruptured at the site of the band.
He has used cuffs and spiral strips of the fresh aorta of a dog wound
about the aorta of another dog. The spiral strips are safer than the
cuffs, as in two instances of the application of the latter, the mattress
sutures taken to hold its flaps together cut part way through, and
being thus brought in contact with the aortic wall, wore a minute hole
in the vessel through which the animal bled to death. To each end of
the band of fresh tissue a narrow tape is sewn,, to facilitate the manipu-
lation of the transplant, which is wound twice about the aorta. When
one or two stitches have been taken at one end to liold the contiguous
edges of the spiral together at this point, the other end of the strip is
pulled upon until the aorta is occluded to a little more than the desired
amount, and then two additional stitches are taken to maintain the
constriction. In some cases there has been absorption of the band,
and the lumen of the aorta has been restored. If, however, tlie
constriction can be maintained for two months, or even one, it might
effect cure of an aneurysm ; and if not, a totally occluding ligatures
might be applied after such a lapse of time without great risk, and
possibly the aneurysm might in some cases be excised. The desirability
of transplanting a segment of vessel, when feasible, must always be
borne in mind. Francesco Nassetti," of Siena, antedated Halsted's
experiments by fifty-six days, as he applied a band of fascia about
the carotid artery, and hence the credit of the idea belongs to him.

References, — ^Rev. de Chir. 1913, 337 ; Med, Jour. 1913, i. May 10 ;

^Bost, Med, and Suvg, Jour. 1913, i, 35 ; Went, med, Woch, 1913, 1147 ; '^Ann.
Suvg. 1913^ h, 269; ^ Johns Hop. Hosp. Bull. 1912, 217, Ann, Surg.

iQii. h> 1S3 ; ’^Aiii della R. Acad, dei Fisiocrit. di Siena, 1912, April 2O.

ANGINA PECTORIS

MEDICAL ANNUAL

II^

ANGINA PECTORIS, Carey Coombs, M,D., M.R.C.P.

Fiessingei',’ studying eighty cases, thinks the coronary factor in the
causation of angina has received too much attention. He divides the
causes into coronary disease, aortic and myocardial disease, nephritic
hypertension, aerophagy, and obesity. Angina, according to this
writer, is a “ neuralgia of the periaortic fibres." Prolonged rest in bed
is essential in most cases. A system of Small Meals of one course
only, repeated every two hours — ^making seven such meals diiring the
day — is of much benefit. Roast poultry, fish, or ham may be given
once daily when the excretory action of the kidneys is satisfactory,
and after each meal, if solid in character, a claret-glassful of hot water
should be taken.

Coronary angina, being often syphilitic, may demand Specific treat-
ment ; the Wassermann reaction may be called upon to decide this.
Theobromine and Trinitrin are also useful. In the angina of aortic
insufficiency, syphilitic infection and coronary disease are often partly
responsible. Moderate doses of Potassium Iodide are called for in
such, often with rest in bed up to two months. If associated with
myocardial disease, the angina may be relieved by combining Digitalin
with Theobromine. Patients of this class often need rest in bed for a
month, as much to soothe an excitable nervous system as to refresh
the heart. In hypertensive angina relief may come spontaneously from
dilatation of the auricle under over-stress ; when this occurs, the
pains aie likely to be mitigated. In hypertensive cases where this
relief does not occur, a Lac to- vegetarian Dietary on the system of
frequent small meals may be given, while frequent Laxatives an*
desirable. Theobromine and digitalin assure some amelioration of
the symptoms. In cases of obesity and aerophagy a cure is the rule.
Here the system of dietary already referred to is of the utmost
advantage. The loss of weight and flesh in these cases has marvellous
results. The use of theobromine twice daily for a month assists the
cure. These patients, however, ought to be warned against under-
going any fatigue. In the cases of aerophagy the painful crises are
generally evoked by walking. Dyspeptic states are usually the start-
ing-point, and a cachet of Sodium Bicarbonate along with some absorbent
powder after each meal is of benefit. Trinitrin and theobromine are
useless and even harmful. The most usual type of gastric trouble in
these cases is a state of gastric hypersesthesia, with hyperchlorhydria,
pyloric spasm, and secondary fermentation.

Reference . — de VAcad, de MH, 1912. Oct. (Brit. Med. Jour. Epit.
1912, ii, 65).

ANKYLOSTOMIASIS. (See Uncinariasis.)

ANTHRAX.

(FoZ.,1913, />. 106) — French, after considering ' the various modes of treatment in
vogue, concludes : “Although some cases may get well without more than conservative-
antiseptic treatment locally, and although some are benefited by such remedies as
pyocyanose or salvarsan, the method most likely to save life in' consecutive cases,
and in which, therefore, most trust can be placed, is Sclavo’s Anti-anthrax Serum.” -

NEW TitEATMENT

APPENDICITIS

II5

ANOCI-ASSOCIATION. (See An^ sthetics.)

ANUS, DISEASES OP. Sir Charles Bent Ball, Bart., M.Ch., F.R.C.S.

Cancer. — G. H. Makins^ records a remarkable case of the combina-
tion of columnar carcinoma and scaly epithelial carcinoma at the anus.
The patient, a man aged 72, came under observation in April, 1909,
with a sore at the anus which had been present some months. On
examination, a smooth circular ulcer was seen, involving the back and
left margin of the anus. The ulcer was three inches in diameter, and
raised above the surface, but there was no induration of the margins
or base of the area affected ; it extended within the anal canal, but
the rectum above it was normal.

It was dissected away and a microscopical examination made,
which showed it to be a squamous epithelioma, apparently invading a
columnar carcinoma. Nineteen months after operation the patient
was again seen ; a nodular flat tumour occupied the region of the scar ;
it was covered with epithelium and not ulcerated ; no extension into the
ectum could be made out ; it was freety movable, and the inguinal
glands did not appear to be enlarged. The patient refused further
operation, and died of extension of the disease in April, 1913.

Pruritus . — ^At a meeting of the American Proctologic Society, D. H.
Murray^ made a further communication on the cause of pruritus ani,
and the results of treatment. He considers the chronic inflammation
of the skin surrounding the anus, which so frequently spreads to the
scrotum in the male and to the vulva in the female, to be due to a
streptococcic infection in a large proportion of cases. In tw^enty out
of twenty-five cases, the streptococcus was demonstrated b}^ cultiva-
tion. In some cases, as many as seven separate cultures -were made
before the organism was found and .isolated. The streptococcus is
usually found in small chains (four to seven elements). He treats
cases in which this organism has been isolated by an autogenous
Yaccine, made of a uniform strength of 1000 millions per c.c. ; his
initial dose is usuall}^ 130 millions, but in the later injections this is
largely increased.

References. — Jour, of Surg. 1913, i, 332 ; ^Trans, Anicr. FvocioL
Soc. 1913. 112.

APPENDICITIS. Sir Berkeley MoynUian, M.S., 2 -.R.C.S.

Harold Upcott, F.R.C.S.

Diagnosis. — A frequent criticism of the early operation in appendi-
citis is the possibility of errors in diagnosis. Recognizing that early
operation is the safest method of treatment, de Quervain^ examined
the records of 1723 cases of appendicitis operated upon by various
Swiss surgeons, with the object of finding the proportion of cases in
which errors w^re made, and to discover whether these diagnostic
mistakes could be justly considered a drawback to early intervention.
Among the, 1723 patients there were 94 (5 percent)^ which* proved at
the operation not to be suffering froin appendicitis. In 10, a perforated
gastric or .duodenal ulcer was found ; in 2 intestinal; perforations- in

APPENDICITIS Il6 MEDICAL ANNUAL

the ileo-crccal region ; in, 2 intestinal obstruction ; i had acute pancrea-
•litis, and t an acute mesenteric thrombosis. Pneumococcal peritonitis
was mistaken for a,ppendicitis in 5 cases, cholecystitis in 3, and renal’
calculus in i.

Pelvic affections in women are particularly apt to be diagnosed as
appendicitis ; thus there were 9 cases of acute salpingitis, 9 of tubal
abortion or ruptured tubal pregnancy, i case of torsion of the ovary,
and 14 of twisted or ruptured ovarian cysts. Pneumonia led to
errors in diagnosis 7 times ; there were also 3 cases of typhoid, i of
scarlet fever, and i of acute nephritis, submitted to operation.

In a certain proportion of these cases where mistakes were made, the
operation was needed at least as urgently as if it were appendicitis.
In a fifth of the cases, operative treatment, while not urgent, -was
beneficial. In the remainder, operation was not necessary, but could
rarel3^ be proved to be the cause of death.

Fig". 6. — Chronic appendicitis due to thread-worms.

Complications. — Cheever^ points out that the most frequent
complication of acute appendicitis is post-operaiive intestinal stasis.
This is generally due to paralysis of the bowel wall consequent upon
the peritoneal infection ; there are other cases, however, in which the
obstruction is caused by a mechanical twist or kink, most frequently
affecting the terminal ileum. Many of the former group recover
spontaneously, or are relieved by suitable non-operative treatment ;
obstruction from mechanical causes, however, needs early operative
treatment if the patient is to recover, and it is therefore of the greatest
possible importance to recognize these cases. Cheever thinks that a
certain number of cases of this latter group are due to adhesion of the
ileum to the inflamed bed of the appendix on the lateral pelvic wall,
a condition to be suspected if, after a few da^^s of normal convalescence,
symptoms of intestinal stasis appear, in a patient whose inflamed
appendix has been stripped away from the side wall of the pelvis.

A recentl^^ recorded series of cases of intestinal parasites in the
appendix^ seems to support von Moty’s suggestion that different
^^arieties of parasites may give rise to different lesions in the

NEW TREATMENT

APPENDICITIS, CHRONIC

117

appendix ; the thread- worm (Fig, 6) and trichocephalus causing a
chronic inflammation, while the round- worm may lead to a more
acute attack, possibly ending in gangrene. Of ten cases in which
thread-worms were found, only two were acute ; three only of the
cases were in children, one of them being acute. The single cases of
round-worm and Tvichocephahts dispav in the appendix were both
chronic. The latter is also of interest from the fact that the appendix
was the seat of a primary carcinoma.

References. — ^ Joitr. de Chiv, 1913, 384; Med. and Surg. Jour.

1913, i, 719 ; ^Edin. Med. Jour. 1913, i, 437.

APPENDICITIS, CHRONIC. Robert Hutchison. M,D., F.R.C.P,

Diagnosis. — Bassler^ is of opinion that one is not justified in
diagnosing chronic appendicitis unless the appendix is tender. In
order to elicit tenderness, he recommends that one should try to com-
press the appendix against the iliacus muscle by pressing at a point
where the outer border of the right rectus muscle crosses a line drawn
from the umbilicus to the anteiflor superior iliac spine. He proceeds
as follows : Standing at the right and facing the patient (for right-
handed individuals) the thumb is placed vertically on the abdomen, the
tip pointing to the ensiform, when it is slowly pressed backward into
the abdomen, not inward, outward, up, or down. When the thumb
has been sunk about half-way down to the back of the abdominal
cavity, it is swung to the right of the patient at a right angle to the
downward pressure line. This pinches the appendix against the iliacus
muscle and unyielding structures under and at the side of it, and usually
elicits pain or tenderness. It is well, having done this in the inid-
distance between the anterior superior spine and the umbilicus, and
not having obtained tenderness, to move the thumb down about ono-
half inch, performing it again, and so on downward until one has
reached almost to the brim of the pelvis. The same procedure on tlie
left side serves as a control. By means of this method of downward
and then right lateral pressure it is possible to elicit tenderness in the
average case of chronic appendicitis.

Aaron- attaches importance, in the diagnosis of chronic appendicitis,
to referred pain or distress in the epigastriuin, left liypochondriuin,
umbilical, left inguinal, or precordkil regions, when continuous linn
pressure is made over McBurney’s point.

Reder*^ employs rectat palpation in the diagnosis of obscure cases.
In such, there is a point of tenderness on the right side of the rectum
just above the circular ring of muscular fibre which forms what is some-
times known as the valve of O’Beirne. In making the examination,
the patient is comfortably placed upon his back on the examining
table, with both legs flexed. The index finger, well lubricated, is
introduced into the rectum, and a search made for O’Beirne's valve.
This valve is sometimes reached with some difflcult^r, especially when
located high, or when the examining finger is rather short. It is
absolutely necessary that the valve be located. Its recognition is

APPENDICITIS, CHRONIC

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readily perceived, the sensation imparted being very similar to that
which the examining finger experiences when introduced into the os
uteri during the first stage of labour.

The valve having been located, the finger is hooked into it and gentle
traction made upon the structures to test the mobility of that portion
of the rectum. The tip of the finger is allowed to rest within the lumen
of the valve, and the patient asked if he experiences any pain. The
answer is usually No.” Should there be any, it is generally referred
to the sphincter area of the rectum. By allowing the finger to rest
for a short time, this pain will subside. After being assured by the
patient of the total absence of pain, the tip of the finger is gently
pushed upward toward the right iliac fossa, when, in the event of a
lesion of the appendix, the finger will touch a point beyond the valve
that causes the patient great pain. As a control manoeuvre, a similar
point might be touched by sweeping the examining finger toward the
left inguinal fossa, usually with negative results.

Hertz^ speaks highly of the value of Basiedo's sign, which he describes
as follows : ” The test depends upon the production of pain and
tenderness in the right iliac fossa on inflation of the colon \vith air.
For this purpose I use an ordinary rubber rectal flatus tube, which is
connected by a short piece of glass to a pump, such as that used with
the sigmoidoscope. Bastedo recommends that the tube should be
inserted ii or 12 in. into the rectum; but there is no advantage in
introducing it further than just within the ampulla of the rectum —
about an inch and a half from the anus. After the tube has been
inserted, the patient lies flat on his back, and the pump is brought up
between his legs. On now slowly pumping air through the tube, the
colon is seen gradually to distend; and after a certain quantity has
been introduced, an individual who is not suffering from appendicitis
feels a diffuse discomfort in the lower part of the abdomen, but there
is no pain iinless an excessive quantity of air is introduced, in which
case it is not marked on one side more than the other. There is also
no tenderness. Patients suffering from appendicitis, however, generally
experience pain in the right iliac fossa, even if the pain has hitherto
been confined to the epigastrium or the neighbourhood of the umbilicus.
Whenever pain is produced, and in some cases in which none has
been felt, well-marked tenderness is found in the neighbourhood of
McBumey’s point. When tenderness has already been observed in this
situation, it is always much increased by inflation, but it is also found
in cases in which no tenderness has hitherto been noticed in spite of
frequent examinations. In a number of instances, I have observed a
further exceedingly characteristic symptom ; the pain is referred to
the epigastrium when pressure is exerted in the right iliac fossa,
after inflation, the epigastric pain being identical in character
with that which formed the chief syrnptom of which the patient
complained.'

Reiterences. — ^Amer. Jour. Med. Sci. 1913, ii, 204 ; ^Jour. Amer. Med.
Assoc. 1913, i, 350 ; ^Surg. Gyn. and Obst, 1913, i, 261 ; ^Lancet, 1913, i, 816.

KEW TREATMENT

ARTERIES, SURGERY OF

1 19

ARSEIJICAL CANCER. E, Graham Little, M.D,, F.R.C.P,

Nutt, Beattie, and Pye Smith^ review 31 cases, one of them a new
observation. In nearly all of these, arsenic had been taken for many
years ; in nearly all, hyperkeratosis was present, especially of the palm
and soles ; in fully half, the cancerous lesions were multiple ; in a fourth
of the cases, the age of the patients was below thirty-five years. The
epitheliomatous process usually started with a keratosis, on the upper
extremity in nearly two-thirds. Excision of the cancerous lesion or
amputation of the affected part was practised in two-thirds, in many
cases with subsequent local recurrence ; in about a fourth of the cases,
metastasis in internal tissues was the termination. Three times as
many men as w’omen were affected. The presence of arsenic in the
tissues seems to have something of the effect of old age in weakening
the resistance to cancer ; frequently repeated slight injury determines
the incidence of the disease.

Treatment. — On the first indication of the earliest epitheliomatous
change, viz,, keratosis, the drug should be withdrawn, if it is being taken.
Local conditions, e.g., warts, may be best treated by Freezing with
Carbon Dioxide. Where there are fissures or ulcers which prove
intractable to treatment for more than a month, Erasion and Skin
Grafting are recommended. When epithelioma is diagnosed, free
Excision or even Amputation of the part, e.g., a finger or hand, should
be practised.

Reference. — '^Lancet, 1913, July and August.

ARTERIES, SURGERY OP. {See also Aneurysms, Surgery of.)

Priestley Leech, F,R,C,S.

Arterio-venous Anastomoses. — Bernheim,^ of Baltimore, reports an
extraordinary case of reversal of the blood current in all four extremi-
ties. The patient was a young woman, 26 years of age, in whom arterio-
venous anastomosis was performed in the left and then in right
leg2 for Raynaud's disease in 1911. In 1912 the same coiulition-'-paiii,
actual and threatened gangrene — necessitated reversal of the circulation
in both arms; this was done in the left arm on Jan nary 22,
and in the right on March 5, 19x2. Operation was successful in each
instance, the brachial artery and vein being united by lateral anasto-
mosis. During the coui'se of operation the only apparent abnormality
noted was the rather small size of the artery and the severity of its
contraction on the slightest manipulation. Tlxc technique was as
follows : both vein and artery were incised at right angles to the
direction of the blood-stream ; the lips of the wound thus spring apart
and tend to remain so. The vessels were united with a single con-
tinuous thread, and the vein was tied off securely above, }>roximal
to the site of anastomosis.

Bernheim thinks that Coenen's views® as to the impossibility of the
procedure on physiological grounds are not sound, and that judgment
ought to be reserved until enough operations have been done by
surgeons specially skilled in vascular work, to justify areally unbiassed
analysis. This method of side-to-side anastomosis is simpler than the

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ciid-to-end, and causes far less risk to the patient in case of failure.
Bcrnheim’s patient has benefited very much in her left leg and both
arms, but still has pain at times in her right leg.

VascAtlar Anastomosis. — Porta, of Siena,* describes the following
method of end-to>end suture of blood vessels. The only objections
seem to be that it is not applicable to very small vessels, and it reduces
the length of the arteries ; but as a rule this latter is not a serious
matter. On the other hand, it does not reduce the diameter of the
vessels, it affords a wide coaptation of the vessel endothelium, and
reduces to a minimum the number of threads projecting into the lumen.
At each of the ends of the divided vessel four flaps are cut {Fig. j a),
of the same size, and a few millimetres long. At the middle of the base
of one flap a loop of silk is passed from without inwards, and then* from
within outwards through the corresponding flap of the other end of the

Fiii\ 7. — Porta’s method of end-to*end suture of blood-vessels.

vessel {Fig. 7 c). The loop is divided, and the threads are tied on

either side {Fig. ^d). The same manoeuvre is repeated with the other
flaps. If, after suturing them all, a few drops of blood escape at the
corners, a suture may be passed penetrating the external coats of the
vessel only and not the endothelium.

Vein Grafting for Maintenance of a Direct Arterial Circulation . —
Hogarth Pringle^* reports two interesting cases where an aneurysm
was excised and the continuity of the artery restored by the grafting
of a portion of a vein. In the first case a popliteal aneurysm was
excised and a gap of 2 in. left in the artery ; a piece of the internal
saphena vein 4 in, long w'as excised, and each end was sutured by
Carrel’s circular suture to the divided ends of the popliteal artery.
Recovery was uneventful. The second patient was a boy who had
a traumatic aneur3?sm of the right brachial arter^^. This was excised
and treated in the same wsiy, with a successful result.

References. — ^Jouy. Amer. Med. Assoc. 1913, t 3<3o ; “Ann. Sing. 1912.
i; 195 ; ^ Beit . c . klin. CJiir. 1911, xxv, i {see also 'NIedical Annual, 1913,
1 12) ; ‘^Presse Med, 1913, 73. ; ^Lancet, 1913. i. 1795.

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121

ARTERIOSCLEROSIS

ARTERIOSCLEROSIS. Carey Coombs, IVLD., M.R.C.P.

Diagnosis. — Hertzelli says that if the circulation be completely
interrupted by pneumatic pressure in both legs and one arm of a
person at rest, the blood-pressure in the remaining arm rises, in normal
persons by 5 mm. Hg, in arteriosclerotics by as much as 60 mm.
The actual extent of the rise \*aries, probably according as the sclerotic
process implicates the whole or part only of. the arterial tree. The
explanation lies in this, that the diseased arteries are so hardened
that they cannot expand to meet the demand for space thrust upon
them by compression of the other vessels, and the blood crowded into
them therefore rises in pressure.

Prevention. — ^Bishop^ thinks that periodic chemical examination
of individuals past middle life would detect idiosyncrasies to protein
and amino -acid poisoning, and would enable us to take steps to prevent
these processes from leading to arteriosclerosis and premature cardio-
vascular decay. He says that for such people saline laxatives are
inferior to Castor Oil, because of their disturbance of the chemical and
osmotic processes of the body.

Treatment. — A discussion at the Medical Society of London, opened
by De Havilland Hali,'^ serves at least to emphasize the close inter-
1 elation between high blood-pressure and arterial degeneration. The
introducer’s remarks on treatment are very practical. He says of
men strenuously occupied by mental work, that he endeavours to
meet the requirements of the case by suggesting that the patient
should leave off earlier than he has been accustomed, and take an
afternoon oif every week, in addition to the whole of Saturday. It
is, however, impossible to lay down any general rule.

As for Diet, the amount of meat nearly always needs reducing. In
advanced cases, meat, and soups made from stock should be discontinued
entirely. The diet should consist of fish, poultry, vegetables, cheese,
milk, oatmeal, bread, and farinaceous puddings. Honey has been
recommended. Some patients derive much benefit from soured milk.
Half a pint to a pint may be taken daily. Excess of salt is injurious.
The patient should endeavour to reduce gradually the cpiantity of
food to as little as is sufficient to keep him in good condition. If the
patient be instructed to eat very slowly and to inastica-te liis food
thoioughty, he will find that he is satisfied with a smaller quantity
than would otherwise be required. Should the patient be obese, thci'o
will aiise certain difficulties about the diet. Sugai should be replaced
by saccharin or saxin. Potatoes, turnips, carrots, and parsnip.s
should be eschewed. Crisp toast, plasmon, or gluten bread should
be taken instead of ordinary bread. Among biscuits, kalari, akoll,
apax, and spartan are useful.

The amount of tea and coffee should be strictly limited. Black coffee
should be prohibited. Patients should abstain from alcohol, though in
the case of those who have a feeble digestion, or who seem much upset
by the deprivation of all alcohol, a small quantity of whisky, say an
ounce and a half daily, or an equivalent quantity of a dry sherry or

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MEDICAL ANNUAL

moselle, may be allowed. An abundant supply of water, free from
chalk, is desirable. A pint and a half should be drunk daily, apart
from meals, and preferably hot. If the hat taste of distilled water
be objected to, it may be flavoured with a little lemon-juice. Less
than 2 oz. of tobacco should be smoked weekly, and if the patient
can be induced to give it up entirely, so much the better.

A daily tepid oi warm bath is helpful ; Turkish baths are as a rule
contraindicated. Walking, riding, and golf are suitable forms of open-
air exercise for most arteriosclerotics, who often need encouragement
in the matter of fresh air. As for drugs. Hall laid particular stress
on the management of the bowels, which should act daily without
strain ; the aperients mentioned, beside Table Waters, are Gascara,
PuIy. Glycyrrhiz® Co., and Pil. Goloc. c. Hyoscy. He has lately found
Paraffin in doses of a dessertspoonful to a tablespoonful, at night and
also if necessary in the morning, comfortable and fairly efficient. The
Iodides are very useful ; Bromide may be added in the case of restless
pel sons ; and for those who cannot tolerate potassium or sodium iodide,
lodoglidlne or lodipin may be tried. For obese subjects, Thyroid
Extract is useful ; the dose should rarely exceed 2J gr. three times
daily. Like most clinicians at the present time, he reset ves vaso-
dilators for angiospastic crises (angina, headache).

To people who can afford the time and money, a course of Spa Treat-
ment can be recommended with confidence. Among British resorts,
Hanogate, Llandrindod, and Strathpeffer are the most beneficial. On
the Continent, Contr^xeville, Vittel, Vich}^, and Kissingen are the
most advantageous places. For the obese, Marienbad and Carlsbad
are especially indicated.

In the subsequent discussion, Luff emphasized the prominent part
which intestinal intoxication appears to play in the production of
arterial disease, and the important indication for treatment which
this affords ; and extolled Egypt as a resort for sclerotic persons.
By several speakers allusion was made to the harm done by excessive
sphygmomanometry ; many arteriosclerotics are enslaved by
unreasonable fear of high blood-pressure, and it is particularly
important to prevent this, in view of the influence of mental stress
in the production of arterial lesions.

Intermittent Limp, — ^Pick's experience of thirteen cases leads him
to place this phenomenon among the varied manifestations of arterial
disease. His patients were all men, and all except two were over
fifty years old. All of them were smokers, six being excessive tobacco
consumers. Other possible factors were diabetes, gout, syphilis, renal
disease, and overstress. In three cases symptoms analogous to those
constituting the limp were apparent in the arm. The treatment
consists in removal of the cause or causes, so far as this is practicable ;
administration of Iodine in various forms, inhalations of iodine vapour
being particularly preferred ; and Respiration of Air under Lowered
Pressure.

References. — '^yiiinch. med. Woch. 1912, 2677; -Jour. Amer. Med.
Assoc. I9i3> t 803 ; ^Clin. Jour. 1913, 161 ; ^Berl. klin. Woch. 1913, 535.

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ARTHRITIS, RHEUMATOID

ARTHRITIS, GONORRH(EAL. {See Gonorrhcea.)

ARTHRITIS, RHEUMATOID, Herbert French, M,D., F.R,C,P.

Billings,^ with several co-workers, has carried out extensive
researches upon cases of rheumatoid arthritis, and lays particular
stress upon chronic focal infection elsewhere in the body as the most
important causative factor.

Lindsay^ describes the cases of rheumatoid arthritis in children that
have come under his personal observation, and agrees with those who
regard rheumatoid arthritis, arthritis deformans, and Still’s disease
as one and the same thing, due to infective or toxic agencies affecting
the articular soft parts and the tissues around them. There is no
essential distinction between rheumatoid arthritis in adults and Still’s
disease in children, though in the latter the malady tends to be more
rapid in its progress and more deforming in its results.

Vasomotor Phenomena are well known in connection with rheuma-
toid arthritis ; but it is less generally recognized that the vasomotor
symptoms may occur not merely in association with the joint lesions,
but also as premonitory signs for months or years before actual arthritis
develops. That this is so is pointed out by Lindsay,® who investigated
the subject in connection mth 153 consecutive cases of true rheumatoid
arthritis (as distinct from osteo-arthritis). Vasomotor disturbances
were exhibited by 108, and in 103 of these preceded the joint mischief,
and were the earliest sign of anything amiss. The symptoms ranged
in degree from slight numbness and blanching of the terminal phalanges
of one or several fingers, to changes so severe as to be indistinguishable
from true Raynaud’s disease. The commonest phenomena were
attacks of coldness and numbness of fingers and hands, a tendenc)^ for
fingers to go dead white on little provocation, recurrent clammy
sweatings of the palms and soles, with feelings of discomfort, or of pins
and needles, in various fingers or toes. The interval between the
beginning of such vasomotor phenomena and the onset of joint
inflammation varies from a few weeks to many 3^ears.

Gertrude H. G. Hickling^ investigated the blood-pressure in fifty
consecutive cases of rheumatoid arthritis of the hospital class, using
Oliver’s compressed air-haemomanometer. The net results found w^erc
that the blood-pressures in these cases do not differ materially from
those of average persons of the same ages ; and the bath treatment had
little effect upon them.

The same writer, in another paper,® analyzes the clinical aspects of
100 consecutive cases of rheumatoid arthritis in women who came to
Buxton for treatment. She summarizes her observations as follows

Reckoning from the time of onset, the disease was more common in
single than in married women. Most cases began in the years twenty-
one to twenty-five ; the onset was earlier when a family histor}^ of
arthritic disease was present. Occupation had no appreciable influence,
except that dressmakers formed a high proportion. Previous health
had more often been good than poor. Ten per cent gave a history of
rheumatic fever or chorea. An arthritic hereditary tendency was

ARTHRITIS, RHEUIVIATOID

124

MEDICAL ANNUAL

well marked, but the frequency of phthisis in the family history of
rheumatoid patients appears to be an independent condition, due only
to the prevalence of consumption amongst the hospital class. Pre-
disposing causes are any conditions which lower the resistance of the
body. Germ infection is the only exciting agent which affords a
satisfactory explanation of the various types of onset. Sudden and
gradual onset occurred with equal frequency. At all ages, the ma-jority
of cases^began in the hands, particularly in the proximal interphalangeal
joints. The clinical course was largely influenced by the occurrence
of one or more acute attacks. Long quiescent periods were a striking
feature. The polyarticular nature of the disease was illustrated, and
no joint was immune. Bilateral symmetry was often noted, most
marked in the hands, and to a less extent in the feet. Flat-foot was so
frequent an accompaniment as to suggest the advisability of prophy-
lactic measures in all cases. Valvular heart disease occui*red only in

cases with a history of
acute rheumatism.
Tachycardia was the
rule, and pulse-rate bore
no relation to the dura-
tion of the disease. Im-
perfect mastication from
absence of teeth ac-
counted for a number
of the frequent cases of
dyspepsia. Menstruation
had usually no effect on
joint symptoms. Vaso-
motor disturbances and
trophic changes were
often present. A ten-
dency to goitre was
relatively frequent,
whilst nearly one-third of the cases had had enlarged lymph-glands.
Heberden’s nodes were only observed in six patients, all over forty, but
subcutaneous fibrous nodules were often met with. The nutrition of
the patients was usually poor and the general health depressed, whilst
a peculiar type of countenance frequently developed.

Hickling draws attention to the pronounced local oedema that
accompanies the swelling of the joints ; this is shown by the ribbed-
stocking marks in the accompanying illustration [Fig. 8).

Treatment. — In regard to treatment of the disease in children,
Lindsay^ says the first thing is to try and find the source of infection ;
a systematic examination of all the orifices of the body — the mouth,
nose, ears, rectum, and vagina — ought to be made, and any infective
focus treated ; a Vaccine may be prepared, if possible, and used.
All cases, he believes, should be Kept in Bed at their onset, this being
the obvious line to follow in the more acute stages with painful joints

Fig. 8. — Rheumatoid arthritis, showing the oedema of
the knee joints.

NEW TREATMENT 125 ARTHRITIS, RHEUMATOID

and constitutional disturbances. Complete Rest of the affected joints
is essential during the early stages. Rest alone will give more relief
to the pain in the joints than any local applications or general medicinal
treatment. Even cases with insidious onset should be rested, as
getting about on joints subacutely affected is harmful and prolongs
the attack on the joint. If possible, as soon as the case is diagnosed,
and if the means of the parents permit, such children ought to be taken
to some part of the country which most closely approximates to the
ideal climate — dry, warm, equable, inland, preferably highly situated
and well sheltered. It is disastrous to allow such children to be
subjected to damp and to wide variations of temperature.

Diet . — During the febrile stages the patient should be kept on a milk
diet. In all other stages the diet should be a generous one. Cream,
butter, and other fatty foods are particularly indicated, and are -well
borne.

Medicinal Remedies . — There is no specific. Guaiacol Carbonate
gr. 5, t.i.d., administered over a period of several months at a time, is
considered by many to do good. Syr. Ferr. lodidi is another useful
drug. The Salicylate group is very uncertain in its action. In some
of the more acute cases, however, salicylates seem to cut short the
attack and relieve the arthritic pain. Aceto-salicylic Acid, in small
doses of 3 to 5 gr. t.i.d., or oftener on painful days, is a favourite
remedy, but should not be employed over a long period of time. General
tonics are frequently indicated, as these patients are so often in a low
state of health. Local Applications to the affected joints, such as oil
of wintergreen, iodex, lin. pot. iodidi c. sapone, are useful in the various
forms of joint stiffness and pain. The writer has had some experience
of Bier’s Congestive Treatment of joints in this condition, using elastic-
webbing bandage around the limb proximate to the joints affected.
In one case the result was exceedingly satisfactory. It is of benefit to
begin Massage as soon as there are any signs of muscular wasting.
This ought to be carried out under strict medical supervision. It must
be given very gently, and only over the selected areas where wasting
occurs o\’er muscles, either singly or in small groups. Care must be
exercised not to interfere with acutely inflamed joints. If mavSsagc
can be carried out several tiijies each week it ought to be done, but
would, of course, be discontinued if the manipulations affected the
patient adversely in any way. The results obtained may not be very
obvious, but will in all probability do much to avert the very great
wasting and contracture deformities which are so distressing a feature
in advanced neglected cases. In the later stages, in order to pi event
undue stiffness of the joints. Passive Movements ought to be caxTied
out. These movements ought invariably to be performed by a
masseuse who can be trusted not to apply any force. All movements
must be done gently, and must cease instantly should any signs of
inflammation in the joints manifest themselves.

Aix-massage, as practised at Bath, Buxton, and Harrogate, is
of especial benefit in the later stages. 7apoin* (Berthollet system)

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126

MEDICAT^ ANNUAL

l)aths give relief to the pain and contraction so often present in those
cases, and as they are rather exhausting to children, they are generally
applied locally only. Benefit may also be got from Electric Hot Air.

Such Surgical interference as arthrectomies, tenotomies, etc,, in
order to correct deformities and render limbs of more nse, may be
considered advisable in the later stages, when the condition has run its
course. Lindsay has on several occasions attempted to reduce defor-
mities by straightening out the limbs while the patient was under the
influence of a general anaesthetic. In each case, the contractures were
easily overcome, and remained so while the patient was anaesthetized,,
but the condition returned as soon as the anaesthetic influence had
been removed. In such cases it does not appear to be of any avail
to apply splints, as even after a considerable interval, the contracture
returns to its former state on their removal.

Vaccines. — Carmalt Jones® gives an account of 20 consecutive and
unselected cases of rheumatoid arthritis in which, as the result of finding
Streptococcus fcacalis in abundance in the stools, he used a vaccine
prepared from this streptococcus. One case was cured, 6 were greatly
improved, 6 more showed some improvement, 6 remained unchanged,
and I became much worse. He concludes that some cases are due to
the absorption of streptococci from a portion of the alimentary canal,
and may be much benefited by streptococcal vaccines.

Warren Crowe^ holds that much information as to the bacteriology
of rheumatoid arthritis is to be obtained by examination of the %mne.
He finds it unnecessary to catheterize the patient, provided the latter
is intelligent ; if he is supplied with a small sterile specimen tube, the
mouth of the latter may be held for a moment in the stream of urine
towards the end of micturition, and the necessary specimen thus
obtained with the greatest ease. x\fter centrifuging, the deposit is
examined microscopically and planted out on an agar plate. After
forty-eight hours, all varieties distinguished are subcultured on blood-
agar and subsequently differentiated by Fleming’s neutral egg medium.
He describes in considerable detail a staphyloid coccus ” which he has
found in so large a proportion of cases that he thinks it must be the
causal factor in many. The behaviour of a vaccine prepared from this
staphyloid coccus is very different from that prepared from ordinary
staphylococci, in that even a dose of *500,000 may cause a severe
reaction, and until the urine is free from organisms more than 5 million
can seldom be given. The vaccine therefore has to be used with great
caution. Soltau® has also worked with Crowe’s staphyloid coccus A,
and supports the view that it is a causal factor in the arthritis. He
emphasizes the need for the use of very small doses of the. corresponding
vaccine ; in one case the dose had to be reduced to one of 1 50,000 at
first ; he made the injections commonly at intervals of a week. When
reaction occurred, it usually took the form of an increase in the joint
pains and swelling, with slight rise of temperature. The best dose to
begin with is, in his opinion, 500,000 or less, increasing quite cautiously
to a maximum of less than 5 million.

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127

ARTHRITIS, SYPHILITIC

Hughes® confirms what others have found, namely, that it is very
seldom possible to obtain cultures from the fluid withdrawn by punc-
turing the affected joint, either in gonorrhoeal or in rheumatoid arthritis,
but he is in favour of the use of autogenous vaccines prepared from
any obvious source of sepsis in these cases. The commonest foci of
infection are the teeth, the nose and nasopharynx, chronic otorrhoea,
the lungs, the intestinal tract, the uterus, the vagina, and the urethra.
He classifies gonorrhoeal arthritis as only one variety of rheumatoid
arthritis, and regards it as the type of rheumatoid arthritis which best
lends itself to autogenous vaccination.

One of the chief difficulties in carrying out vaccine treatment in
rheumatoid arthritis lies in the obstacles to determining the causal
organism in a particular case. Puncture fluid from the joint is generally
sterile. There may be pyorrhoea, otorrhoea, or vaginal discharge, or
what not, but it does not follow that the organisms in any of these are
really the cause of the joint lesions also. Blood cultures remain sterile
in most of the cases. Hastings^® has therefore prepared suitable
antigens, so that he can test the patient's blood-serum by a complement-
fixation method, analogous to Wassermann's syphilis reaction, against
streptococci, gonococci, pneumococci, and so on, and thus form an
opinion, based on sometMng more than mere guesswork, as to whether
one or other of these suspected organisms — and if so, which — is the
cause of the rheumatoid arthritis.

Porter^^ speaks well of the use of Phylacogen injections in rheumatoid
arthritis. His was a single case only, so that little conclusion can be
drawn from it ; but when other remedies had failed, phylacogen was
used, ten injections in all being given ; 2J c.c. each day for four days,
5 c.c. on the fifth ; then an interval of four days, and a repetition of
the course.

References. — '^Jouv, Amer, Med. Assoc. 1913, ii. 819 ; ^Edin. Med. Jour.
1913^ t 337 J ^Clin. Jour. 1913, i, 268; ^Med. Chron. 1913, Oct. 25 ; ^Ibid.
1913, Mar. 317; ^Brif. Med. Jour. 1913, i. 1047: ’^Lancet, 1913. h I 377 I
^Ibid, 1379 ; ^Brit. Med. Jour. 1913. i. 1267 ; '^^Jouv. Amer. Med. Assoc. 1913,
i, 1208 ; Lancet, 1913, i, 1588.

ARTHRITIS, SYPHILITIC. Herbert French, M.D., F.R.C.P.

Baetz^ had the opportunity of investigating 100 consecutive cases
of acute arthritis among negro labourers on the Panama Canal,
and found 63 of them to be syphilitic. Although there may be other
syphilitic manifestations in some patients, in most the joint lesions
afford the only symptom. The average patient is admitted to the
ward with a multiple, rather subacute, arthritis ; as a rule there is no
fever, and the joint pain is severe only on pressure. The joints usually
involved are the knees, elbows, sternoclavicular, ankle, and wrist.
The finger and toe joints are seldom affected. There is moderate
swelling, but marked effusion is rare ; the involvement of the peri-
articular bursa and of the tendon sheaths is very uncommon; in
other words, the inflammation is limited to the joint, which is merely
boggy and tender to pressure. The most common concomitant sign

ARTHRITIS, SYPHILITIC

128

MEDICAL ANNUAL

of syphilis was acute osteo-periostitis of the sternum and of the long
bones, especially of the lateral surface of the tibia, the patient usually
being very sensitive even to moderate pressure when this exists. Most
of the cases occurred in the late secondary stage, the Wassermann test
was positive, and with treatment by Iodide of Potassium and Mercury,
or, better still, by Salvarsan, the arthritic pains disappeared rapidly
and the swelling became scarcely noticeable.

Reference. — ^Jour. Amer. Med. Assoc. 1913, i, 10O5.

ASTHMA. /. J. Perkins, M.B., F.R.C.P.

Etiology. — Dundas Grant, ^ reviewing the influence of nasal disease
in the causation of asthma, states the present position with admirable
candour. The experiments of Dixon and Brodie, proving the presence
of constrictor and dilator fibres governing the bronchial calibre, the
most important reflex for which they found in the nasal mucosa,
especially over the upper and posterior parts of the septum, would
predispose one to believe that the condition of the nose must have
an important connection with the disease. Grant quotes figures from
West of 500 cases of asthma with pathological nasal changes in 143,
and on the other hand of 649 cases of nasal polypus with asthma in
but 47. It is therefore obvious that nasal polypus is not a frequent
cause of asthma, but that in asthma various pathological nasal changes
are comparatively frequent.

As to the effect of Nasal Operation on asthma, it is interesting to note
that of Lublinsky’s 143 cases, 27 were cured and 13 improved. Dundas
Grant himself found in 107 cases of asthma sent to him at the Brompton
Hospital that there were 68 with nasal changes so well marked as to
call for operation, 31 in which the changes were so slight that operation
was not indicated, and 8 with no nasal abnormality. Reports were
obtained later from 44 of the serious cases in which a definite operation
was undertaken. Cure was obtained in 8, great improvement in 2,
improvement in 25, no improvement in 9 ; of the 9 who reported no
improvement, 4 came up for further examination, and it was found
that in all nasal disease was still present. It is interesting to note the
wide spread of the nasal disease, as indicated by the nature of the
operations, and the comparatively small part that nasal polypi played.
Submucous resection of the septum was done in 5 ; galvano-cautery
to the septum for turgescence of the tubercle, 10 ; galvano-cautery to
turbinals and septum, i, to turbinals, 6; removal of nasal polypi, 9,
of hypertrophied anterior lip of hiatus semilunaris, 2, of adenoids, 2,
of portion of middle turbinal, 8 ; opening antrum of Highmore, i.
In conclusion. Grant says that in every case of asthma a rational
investigation as to the presence of signs or symptoms of nasal disease
should be made, while in any case of nasal disease the presence of
asthma is an additional indication for activity in treatment.

Speaking of asthma in children, Bellingham Smith- controverts the
opinion held by the majority of authors that the greater number of
cases do not start till between five and ten years of age. Though the

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129

ASTHMA

dry adult type with its intense dyspnoea is not common before five
years, there is a distinct type of infantile asthma which may commence,
according to his experience, almost as early as birth. In 34 cases
seen by him, no less than 20 had their first attack within the first twelve
months of life, figures supported by Comby, who in 75 cases found
56 under three ^^ears of age. Two types of asthma, then, can be met
with in childhood : one appearing bet^veen birth and five years of age,
the second between five and ten years. Smith describes the latter
as a dry asthma, dyspnoea being the prominent feature, the former
as a moist asthma, the predominant feature being the accompanying
or following bronchitis. The dry form of later childhood need not
detain us, as it conforms so closely to the adult t^^pe ; the description
of the symptoms of the early or infantile type will not be out of place,
as the true nature of the condition at first sight is not easih?- recognized.
Commonly, the attack is of the following nature : a young child or
infant has a. cough or symptoms of slight bronchitis, in the midst of
Avhicii he is seized with a breathlessness which suggests broncho-
pneumonia, though on examination dyspnoea is found to be out of all
proportion to the physical signs in the chest. After lasting a variable
time, the attack is followed by a period of bronchitis with numerous
rhonchi and rales, which may last for two or tliree weeks. The attack
is succeeded at some later date by a fresh outbreak of bronchitis and
breathlessness, and in this recurrent character Smith finds the clue to
asthma in early life, an especially valuable point, as the dyspnoea is
frequently not especially intense. Laryngitis stridulosa causes most
difificulty in differential diagnosis, according to this author. A child
who has had a little catairh during the day wakes up suddenly with
intense difficulty in breathing ; there is an incessant ringing or barking-
cough, a hoarse voice, considerable inspiratory stridor, and restlessness :
such attacks as are frequent in a child with any infiammatory condition
of the upper respiratory passages. The pallor, the cyanosis, the
expirator}^ stridor, the unaltered voice, and the immobility character-
istic of true asthma should prevent mistake, while the physical signs
of the tw'O cases are entirely different. In astlima the chest is
distended and motionless, -while in laryngitis respiration is free except
for the laryngeal obstruction ; the stridor in asthma is expiratory,
in the laryngeal cases inspiratory. In contrast with broncho-
pneumonia, the recurrent nature of the attacks, the absence of lever,
the intense dyspnoea out of proportion to the physical signs, stamp the
case as one of asthma. As regards the chest, hyper-resonance and
diffuse moist sounds, as against the evidence of consolidation in ‘
pneumonia, are the criterion. Whenever there is a history of recurrent
attacks of pneumonia in childhood, asthma may always be suspected ; ■
and Smith quotes a case of a boy, aged five, who had been admitted to
hospital on four separate occasions for pneumonia, but when seen by
him in what was supposed to be a fifth attack had typical asthma.

Treatment. — Smith speaks of the importance of first of all RelieYing .
any Source of Irritation or chronic ill-health, such as adenoids, consti-

ASTHMA

MEDICAL ANNUAL

130

pation, and rickets. He has seen the regulation of the bowels, or a
course of rhubarb and soda, effect a cure when dosage with iodides and
the antispasmodics has failed. The immediate drug treatment he
considers under two heads : (i) during an acute attack, (2) during
the interval. If the attacks only occur at night, he gives at bedtime
a regular mixture of Potassium Iodide, Belladonna, and ethereal
tincture of Lobelia, and finds it safe to give ^ gr. of iodide for
each year of life, 2 to 10 min. of belladonna from infancy to ten years,
and lobelia in minim doses for every year of life up to 5 min. If the
attacks occur by day as well as by night, the same prescription is given
in smaller doses three times a day. The iodides, in his experience, are
the sheet anchor in this disease in early life ; they should be given
for six or eight weeks, then omitted for a fortnight and replaced by
arsenic, after which the course of iodides can be renewed. Of other
drugs he does not speak very highly. He has never made use of
morphia himself in the attack, nor indeed of any of the sedatives,
except a little Bromide or Phenazone when the child is hyper-excitable.
An injection of 3 to 5 min. of Adrenalin can be given ; while in an acute
attack in an infant, Hot Baths have a sedative effect, or the kettle
with Medicated Steam may be tried.

References. — ^Pract. 1913, i, 914 ; ^Ibid. 924.

AURICULAR FIBRILLATION. Carey Coombs, M.D„ M.R.C.P.

To the full description given in last year’s Medical Annual of this
condition, usually a terminal phase of chronic cardiac disease, little
need be added. The cardinal features are total irregularity of the
pulse and disappearance of the evidences of auricular systole (absence
of presystolic bruit, of “ A ” wave of jugular curve, and of “ P "
variation of electrocardiagram).

Etiology. — ^Lea’s^ summary shows the etiological importance of
rheumatic carditis, which usually brings about this form of cardiac
failure by causing mitral stenosis, thus (presumably) leading to
auricular over-stress, with subsequent degeneration ; a history of
rheumatic infection was obtained in 45 per cent of his cases, and it is
to be presumed that a considerable proportion of those in which no
such histoiy was forthcoming were nevertheless rheumatic. G. A.
Sutherland and the present writer^ record a case of fulminating
rheumatic carditis in which the signs of auricular fibrillation developed,
and were associated post mortem with extremely severe inflammatory
and degenerative changes throughout the myocardium, particularly in
the left ventricle and the right auricle. Cohn,^ on the other hand, failed
to find any definite lesion in the hearts of three horses who exhibited
this type of arrhythmia during life ; and Gossage and Braxton Hicks^
quote cases which suggest that it may arise in previously healthy
hearts, and that in such its essential cause may lie outside the heart
altogether. [The writer has under observation a case which lends
strong support to this hypothesis. — C. C.]

TREATMENTr — Cushny, Morris, and Silberb^rg® find that the action

NEW TREATMENT

AURICULAR FLUTTER

131

of Digitalis, which is often so wonderfully beneficial in auricular
fibrillation if given in adequate doses, is to be ascribed to its direct
efiect on the myocardium, augmenting its contractile power, and not to
any indirect vagus-stimulating action. They agree that its reduction
of pulse-rate may be due to depression of conductivity^ or of the
excitability of the myocardium ; but they look upon these effects, if
present, as dependent entirely on the cardiotonic action of the drug.
This is true of allied drugs, such as strophanthus, as well as of
digitalis itself..

Eggleston's® investigations show that digitalis causes vomiting only
after absorption into the general circulation, and not by virtue of any
gastric irritant effect. The moral pf this is that the use of digitalis in
cases otherwise suitable is not to be prohibited on account of gastro-
intestinal symptoms.

References. — '^Lancet, 1912, ii, 1215 ; ^Heart, v, 15 ; ^Ibid. iv, 221 ;
^Quavt. Jour. Med. 1913, July, 435; ^Heart, iv, 33; ^Jonr. Amer. Med.
Assoc. 1913, ii.''

AURICULAR FLUTTER. Carey Coombs, M.D., M.R.C.P.

This has emerged as an interesting entity, during the last year or
two, from several clinical groups in which it had hitherto been buried.
Papers by Ritchie, ^ Lewis,®, ^ Hay, ® Hume,’, ® and others have
given clearer definition to our ideas on the subject, though much
remains obscuie and nebulous. The term auricular flutter " should
be reserved for a condition in which the auricles beat regularly at a
rate of 200 per minute, or faster still.

Etiology. — Some causative factor is apparent in nineteen out of
twenty-eight cases ; cardiosclero.sis in seven, and chronic valvular disease
of the post-rheumatic type in six, head the list. There are but three
possible examples originating in acute cardiac disease ; two of Hume’s’’
diphtheritic arrhythmias gave some indication of flutter, and in one of
Lewis's cases the irregularity seemed to arise in an attack of influenza.
Practically all the patients were adults, the majority havii^ig reached
or passed middle life. In nine out of twenty-eight cases tlie heart
was apparently normal. Neither exertion nor emotion, nor any of the
conventional provocatives of cardiac over-stress, appears to play any
dominant part in determining its onset.

Pathology. — ^The only definite observation relating to the morbid
anatomy of this condition emanates from Ritchie.- In his case, one
of the post-rheumatic variety, there were the usual diffuse degenerative
phenomena, but showing no particular localization. The fact that
auricular flutter is a penultimate phase in many cases, coupled with
its almost invariable association with chronic cardiac disease, suggests
that it is an outcome of degenerative changes, and not of inflammation,
as a rule. This is in accord with its close relation to auricular fibrilla-
tion. Observations by various workers lend support to the view
expressed by Lewis,® that there is a series of perversions of auricular
function, extending from single premature auricular contractions at the
one end, through small groups of the same and paroxysms of tachy-

AURICULAR FLUTTER

MEDICAL .ANNUAL

cardia from single auricular foci, to auricular flutter, and thus on to
auricular librillation. Ritchie^ has noted a stage intermediate between
the last two. Translating this concept into simpler language, what is
suggested is that the degenerating auricular wall becomes over-excitable ;
that this occurs at first occasionally and in one spot ; that later a
spot of this kind becomes the source of a rapid regular rhythm ; that
to this foci others of the same kind, leading to a multiplication of
abnormally fast rhythms, are added ; and that the final result, auricular
fibrillation, represents a condition in which the normal auricular
rhythm has been entirely replaced hy multiple rhythms arising from
many auricular foci, these rhythms racing one another in a confused
medley into the ventricle through the auriculo-ventricular connections,
whose capacity for transmitting such impulses is fortunate^ so limited
that many of these irregular stimuli are hindered from troubling the
ventricle.

Symptoms.- — It is not a disease, scarcely even a syndrome ; it is,
rather, itself a symptom. As such, it may occur in connection with
heart disease in any phase, or with no appreciable cardiac lesion
whatever. Like parox37'smal tachycardia, its onset and offset are
abrupt, but unlilce the former, outbursts of which are usually brief,
iiutter continues for weeks, months, or A^ears as a rule. It reacts but
little to external stimuli, though it is influenced by digitalis in a manner
noticed below. The arterial pulse varies widely, and is absolutely
unreliable for diagnosis of the condition : the reason being that the
conduction paths usually fail to transmit more than a certain pi*o-
portion of the abnormally rapid stimuli from auricle to ventricle.
Often it is a definite fraction, half or three-quarters, of these stimuli
that is arrested ; so that if the auricle is beating at 300, the radial
pulse beats at 150 or 75. Even this is not all, however ; those impulses
that do come through from auricle to ventricle may be delayed in
transmission by a variable interval, the result being that the pulse
becomes irregular and sometimes simulates that of total arrhythmia.

Diagnosis. — ^For this graphic records are always essential. When-
ever possible, all cases suspected of flutter should be examined electro-
cardiographically ; but when this is not feasible, jpoligraph records may
display the presence of flutter in the form of a fast regular wave in the
jugular trace. This auricular tachycardia is much more clearly visible
. in the electrocardiogram, as reference to the records of Ritchie^,® and
Lewis® show.

Prognosis. — ^Auricular flutter has no grave significance so far as is
known, except when it occurs in cases of organic heart disease. Here
its importance is twofold : it betrays a fairly advanced degeneration
of the auricular musculature, and it adds to the burden of the heart
by excessive speeding up of the ventricle.

Treatment. — We can fortunately, by means of Digitalis, Strophanthus,
and allied substances, bring about some improvement. Full doses
should be given, and two kinds of effect looked for. In favourable
cases auricular flutter gives place to fibrillation, and on continuing the

NEW TREATMENT

133

gERi-BERl

drug, this is in turn replaced by the normal rhythm. Even when
digitalis fails to bring this about, its depressant action on conductivity
cuts dowTi the number of stimuli troubling the ventricle, which is by
this means afforded a more ample measure of diastolic rest. Tt is
always prudent, even in the absence of obvious cardiac lesions, to
rest patients while their treatment is being carried out.

References — ^Edin. Med. Jouy. 1912, it 485 ; -Ouart. Jour. Med. I 9 i 3 '
vii, i; ‘^Heavt. 1913, iv, 171 ; ^Lancety 1912, it 141S ; ^Liverp. Med.-Chir.
Jour. 1913, SS ; '^Lancet, I9i3> it 9S6 '^Qitart. Jour. Med. 1913, vt 235 :
^ Heart, 1913, v. 25.

BEKI-BERI. Leonard Rogers, M.D., F.R.C.P,

During the past year several Avorkers have continued experimenting
on the relation of diets to beri-beri. R. P. Strong and B. C. CrowelP
have carried out carefully controlled observations on a number of
condemned prisoners in the Bilibid prison at Manila. The men were
isolated in two separate batches ; all their food was weighed, the
amount not eaten by each being also estimated. . The polished Avhitc
rice was specially milled and analyzed, including the percentage of
phosphorus, and every possible precaution taken to exclude any source
of fallacy. The men put on white rice plus uncooked rice polishings,
after a few daj’s refused to continue it, so the control group were then
fed on red rice plus the special diet which all the groups received.
A second group received white rice plus alcoholic extract of rice polish-
ings, while two further groups received only white rice plus the special
diet common to all, which included bacon, onions, lard, bananas,
starch, and sugar, in measured amounts. On the ninety-seventh day
for the first three groups and the eighty-first day for the fourth (white
rice) group, 100 grams of potatoes and 30 grams of dried codfish had
to be added on account of serious loss of weighjt of most of the men.
In Groups II and IV on white rice 4 out 01 6 anc^-. i i respectively
developed typical beri-beri, including cardiac aiY^^ ^'ory symptoms,
with complete loss of knee-jerks, while 2 more group showed

early symptoms of the disease. One more shoAA'ed doubtful signs, while
only 3 out of the 17 escaped entirely. On the other hand, of 6 men in
Gi'oup I on Avhitc rice plus exriact of polishings, 4 escaped altogether,
and 2 developed early symptoms of beri-beri, showing that the amount
of the protecth*e substance in the extract of the polishings was small.
Lastly, of 6 men on i*ed rice only, i developed rather marked
S}Tnptoms of beri-beri, and another only slight cardiac symptoms,
while in the remaining 4 no signs appeared. A post-mortem on
one fatal case on white rice shoAved characteristic lesions of beri-beri,
both naked-eye and microscopical. In all the groups there was marked
loss of weight. In the definite cases the disease developed in from
61 to 75 days on AAdiite rice. As infection and bad hygienic surround-
ings were excluded, it is clear that the AA^hite, or polished, rice diet was
the cause of the disease, although the fact that one fairly marked case
developed on red rice shoAvs that if the diet is very monotonous for a
long time, and much weight is lost, such a diet may occasionally produce

BERf-BERI

134

MEDICAL ANNUAL

the disease. The extract of the polishings is evidently inferior as a
preventive to certain beans and to yeast, wliile the latter are far
cheaper. As they found that a white rice containing 0*37 of phosphorus
pentoxide produced the disease, they think a higher limit than 0*4
should be adopted in any legislative measures taxing white rice as a
preventive measure against beri-beri.

E. B. Vedder^ reports further experiments to determine the nature
of the protective substance. He found that a diet containing a
sufidciency of all the alimentary principles may yet be deficient in the
beri-beri-preventing substance. This accounts for cases reported on
diets other than white rice. By a process of exclusion he found that
the preventing substance is not volatile, is not an inorganic salt, and is
probably not an alkaloid, so that it is probably an organic base, as
claimed by Funk ; and although V edder failed to confirm his work,
he thinks this may be due to slight differences in his method of extrac-
tion, 111 a paper by V edder and E. Clark,® the symptoms and pathology
of the disease are fully discussed and illustrated on the extensive basis
of their numerous experiments. Great prostration and symptoms of
neuritis are combined in varying proportions in different cases, the
former being the more rapid and serious, and also most quickly cured
by extracts of the rice polishings, while the nerve signs take a long
time to disappear. Degenerative changes were always found in the
sciatic nerve, even if no symptoms of neuritis had been present.
Changes were also found in the grey-matter cells of the lumbo-sacral
cord, showing that the central nervous system is also affected. They
suggest that two different vitamines may be essential for proper
metabolism, the absence of one producing prostration and cardiac
failure, and that of the other neuritis, which would account for the
different types of the disease.

' Casimir Funk^ ha^*l^arther investigated the chemical properties of
the vitamine he' ^-^rcced from yeast, and has separated it into three
different substaCr'^ with different melting points and solubility, but
advises the use of the whole vitamine-fraction in the treatment of
beri-beri.

Edie, Evans, B. Moore, Simpson, and Webster,® working in Liverpool,
have continued testing the value of various additions to a rice diet in
preventing or curing polyneuritis in animals. For this purpose casein,
nuclein, and lecithin proved ineffective. They confirmed Fraser and
Stanton's statement that alcoholic extracts of rice meal have protective
and curative preparations if concentrated under a fan, and not on a
water-bath. They next made yeast extracts with large quantities of
methylated spirit, and obtained a substance with powerfully protective
and curative action, which on further purification yielded feathery
crystals. This they have analyzed, and estimated its probable formula.
Creighton Wellman, C, C. Bass, and A, C. Eustis,® working at New
Orleans, have found that white polished Louisiana rice will produce
neuritis in fowls fed exclusively on it, while the same rice unpolished
has no such effect. Pure corn starch also^produces the disease rather

NEW TREATMENT

135

BERI-BERI

more slowly, while a pure cane sugar diet produces it more rapidly than
a polished rice one.

W. Caspari and M. Moszkowski^ record an experiment in which the
last-named placed himself on a polished-rice diet in Berlin for 230 days.
Exact metabolic observations were made for 138 days. Constipation
was the first symptom, followed after a month by nervous and cardiac
symptoms, and oedema of the lower extremities developed. He was
cured rapidly by adding extract of rice polishings to the diet. The
analyses show a very great destruction of protein, which they think
can only be explained by a severe toxic action, and they therefore
hold, in opposition to nearly all other observers, that beri-beri is due,
not to a deficiency of the diet, but to an intoxication.

W. L. Braddon,® who was the first to demonstrate conclusively
that beri-beri was produced by a diet composed almost exclusively of
polished rice, from which the outer albuminous layers had been removed,
records the great reduction of cases and mortality in hospitals, asylums,
etc., in the Malay States. S. Shibayama*'* discusses the present state
of the study of beri-beri in Japan, and says no final conclusion can be
arrived at, the rice theory not being a complete solution of the question
in that country. B. Nocht^*^ accepts the rice theory. He has not
found rice-bran or yeast satisfactory in the treatment of beri-beri, but
prefers raw food-stuffs, or extracts of them, which probably contain a
number of vitamines, all of which are necessary to health.

Carl Lovelace^^ describes the extensive prevalence of beri-beri among
labourers constructing a Brazil railway, in which rice could be excluded
as the cause. The case mortality during two years averaged 15*6 per
cent. The diet was varied and abundant, and in some cases not a
grain of rice had been eaten for many months. The staple foodstuffs
of the labourers were dry biscuit, dried and tinned meat and fish,
beans, and macaroni, rice having been eliminated on account of the
occurrence of beri-beri, but during the following year the cases increased
threefold. Among the attacked were six strong young American
doctors. In 1910 fx*esh meat, onions, and potatoes were included in
the diet, but cases still occurred, and were more prevalent in some
camps than in others.

Prophylaxis, — L. J. McLaughlin^^ writes on beri-beri in infants
ill the Philippines, and concludes that half the total deaths in Manila
were in infants under one year of age, three-fourths of whom were
breast-fed. A little over half these deaths he attributes to beri-beri,
the mothers of nearly all of them also showing some signs of the disease.
The condition can be promptly cured by either feeding the child on
fresh cow’s milk or giving extract of rice polishings, D. Gregg^^ deals
with the same subject, and after a study of the literature accepts the
conclusions above stated.

H. Fraser and A. T. Stanton^^ have published a further paper on the
prevention and cure of beri-beri in continuation of their previous work.
They again discuss a tax on polished rice containing less than 0*4
per cent of phosphorus pentoxide as a preventive measure, and

B‘ERl«BERi 136 MKi^ICAL ANNUAL

consider that if adopted it should be at the point of distribution, but
are doubtful if it is a practicable measure. They have further tested
the curative action of alcoholic extracts of rice polishings, and con-
firm their great value in fowls, and hope to overcome the difficulties
in applying this measure to patients affected with the disease.

H. C. Highet^^ has published a full report on beri-beri and its preven-
tion in Siam, which furnishes conclusive evidence in favour of the
modern views, and confirms the statement that rice containing less
than 0*4 per cent of phosphorus pentoxide is likely to cause beri-beri
if it forms the staple diet. He finds that Siam rice if not milled bej^ond
this point is a safe food, and can readily be prepared by hand or steam
mills. The incubation period of the disease was about sixty days.
The use of imdermilled rice, as advised above, has done away with beri-
beri in all the Siam government institutions and among the gendarmerie,
and is now' applied to the army and navy.

References. — ]onr. Med. Sci. 1912, 271 ; Ubid. 413 ; ’’^Xbid. 423 ;

Med. Jour. 1913, i, 814; ®P/n 7 . Joity. Med. Sci. 1912, 423;®^wr;'. Sac.
Trap. Dis. 1912, No. 20 ; ySerl. klhu Woch. 1913, 1515 ; ^Jouy. Tyop. Med.
1913, 2S2 ; ^Ibid. 2S3 ; ^'^Ibid. 285 ; Joity. Amer. Med. Assoc. 1912, ii, 2134;

Trop. Med. 1912, 370; ^^Bost. Med. mid Surg. Jour. 1913, i, 676;
Lancet, 1912, ii. 1005 ; ^'*Siam Gov. Rep.

BILIARY TRACT, SURGERY OF.

Sir Derkeley lUoynihan, M.S., F.R,C,S.

Harold Upcofi, F.R.C.S.

It is now generally conceded that early operation affords the patient
the best chance of recovery from infective cholecystitis. The details
of the operative treatment are less clearly defined. The majority of
surgeons are content with simple drainage of the gall-bladder. A few
make a practice of cholecystectomy, "while others reserve cystectomy
for gangrenous cases, preferring cholecystostoiny for the majorit}^
After considerable experience, Leriche and Cotte^ prefer Cholecyst-
ectomy a chaud,” on account of the ease of its execution and the
excellence of its results. They hold that it should be the method of
choice in all cases of acute calculous cholecystitis, and that chole-
cystostom^^ should only be performed when excision of the gall-bladder
is impracticable on account of the bad general condition of the
patient, the impossibility of exteriorization of the liver, or extensive
pericholecystitis. They point out that after cystostomy, peritonitis
may develop from secondary perforation of the gall-bladder ; they
have seen sceptic infections of the liver or kidneys, and patients have
died from secondary septicaemia ; and, finally, the troubles of chronic
cholecystitis may supervene. The authors describe the technique,
and insist on the desirability of draining the cystic duct after removal
of the gall-bladder.

Clairmont and v. Haberer in 1910 sought to show the possibility
of a " galligen peritonitis without perforation of the biliary tract.
According to them, there may be a large effusion of bile into the abdo-
minal cavity in cases of common-duct obstruction, without a breach

NEW TREATMENT

^37

BILIARY TRACT

in the walls of the ducts, through which a kind of filtration takes place.
They assume some pathological condition of the walls of the ducts
which causes this permeability. AVolf- also describes three cases in
which the abdomen contained a quantity of bile. In one, a duodenal
perforation was found. In neither of the others could any perforation
be discovered, although one was examined post mortem, Nauwerck
and Lubke,® on the other hand, had the opportunity of examining a
case at autopsy which appeared to support Clairmont and \'on
Haberer’s theory; but the microscope furnished an explanation in the
shape of a minute perforation of the gall-bladder. This was not
sufficient to allow the escape of any fluid when the gall-bladder and
ducts were tested for leakage by the injection of water. Inspection
of the interior of the gall-bladder revealed two or three superficial
mucous erosions. The examination of serial microscopical sections
showed that one of these really extended through the whole thickness
of the wall.

Khantz^ has been able to find 15 cases of biliary hi hi as is in
childhood ; 6 in babies, 5 in children from five to ten, and 4 in girls
from thirteen to seventeen. The pathology and sjnnptoms arc the
same as in adults. Six cases were successfully treated by operation.
Non-calculous cholecj'stitis is even more rare than the above. Khantz
could onW find 5 cases, 3 of which appeared to be secondary to other
infections — appendicitis, scarlet fever, and typhoid. Cholecystectomv'
was done in 4 cases, three times with success.

Sasse^ urges that the operation of Choledocho-duodenostomy should
not be limited to cases of absolute necessity, such as tumours, strictures,
or loss of continuity of the common duct; but advises its more frequent
employment in cases of stone in the common duct, to pro\’ide a free
drainage of the biliary canals, more especially when cholecystectomy
has been performed. He makes a vertical incision in the common duct
immediately above the duodenum. After exploring the duct and
removing any stones, this opening is sutured with two layers of silk
to a vertical incision (transverse to the axis of the intestine) directly
opposite to it, in the first part of the duodenum. He reports 10
cases with good results.

Gall-stones of a siiflicient size to cause obstruction may enter tlic
intestinal tract in three ways. The)* may erode their wa)'' through
the cystic and common ducts by a combination of dilatation witli
pi'essure necrosis and ulceration ; the duct or gall-bladder containing
the calculus may become adherent to the stomach or bowel, a direct
perforation between the viscera allowing the stone to escape into the
intestinal tract ; or it may perforate the gall-bladder or duct and
become enclosed in a local abscess, which may subsequently empty
itself into the stomach or intestine. Having reached the intestine,
the favourite seat of impaction of the stone is in the low*er ileum,
Babcock‘S records an unusual case of pyloric obstruction caused by a
gall-stone in a woman who had a laz'ge umbilical hernia distended
with pus and gas. Some weeks after incision a sinus still remained,

BILIARY TRACT 138 MEDICAL ANNUAL

tlirongli which food escaped shortly after it had been swallowed.
Three and a half months after the abscess had been opened, the sinus
had healed, but there followed pyloric obstruction. Operation was
done under spinal anaasthesia, as the patient was in very bad condition.
The sinus was opened up and found to lead to a perforation in the
anterior wall of the stomach. Immediately below the pyloric ring
was an enormous gall-stone, which was pulled back into the stomach
and removed. Death occurred twenty-four hours later.

On several occasions Stetten" has observed fistulje or symptoms of
biliary obstruction after simple cholecystostomy. Some of these cases
A\'ere re-opened, but the ducts were found free. Aftei; cholecystostomy,
or after freeing and closing the gall-bladder and dropping it back in the
abdomen, the patient w’Oiild be cured. He found the explanation in

a recent case of
cholecystostomy, in
which the gall-
bladder was sutured
to the parietal
peritoneum. O n
removing the tube
a week after oper-
ation, the discharge
promptly ceased.
One week later,
biliary obstruction
developed ; at the
second operation,
the junction of the
hepatic and common
ducts was found
kinked by traction
of the gall-bladder
{Fig. 9). Cystectomy
cured the condition. Stetten considers the possibility of this occur-
rence is an indication against cholecystostomy, and he says that primary
cystectomy is a certain means of preventing it. [This overlooks the
fact that traction on the gall-bladder during cystectomy may lead one
to ligate the hepatic or common duct ; if cholecystostomy is performed
without t he gall-bladder to the peritoneum, a perfectly satis-

factory method, fhe'-accident will not occur. — B, G. A. M. ; H. U.]
References. — ^Rev. ch... Chiy. 1912, S60 ; ^Berl. klin, Wocli. 1912, 2354 ;
^Ibid. 1913, 624 ; ^Centvalb. f. d. Grenzgeh. d. Med. u. Chir. 1913, 545 ; °Aych.
f. kUn. Chiy. 1913, 969; Med. Jour. 1913, i, 1160; Mww. Suvg. 1913.

'i, 182.

BLACKWATER FEVER. Leonard Rogers, M.D., F.R.C.P.

In 1912, Leishman, in a paper on '' Cell-inclusions in the Blood of a
Case of Black-water Fever," described certain bodies showing chromatin
staining, and soon after reported finding similar bodies in another

/'XiT* 9. — Diagram showing angulation of the junction of the
hepatic anU common Uucts after oholecystostomy, N ote dilatation
of ilie hepatic duct and valve-like formation at junction of
hepaticus and choledochus.

NEW TREATMENT

139

BLADDER

case, and suggested they might be protozoal parasites. G. C. Low^
soon after reported having seen similar bodies in the leucocytes in the
blood of cases of fever from Borneo as well as in pellagra, so they are
not peculiar to blackwater fever. A. C. Coles® has also described red-
staining granular structures in the blood of a case of blackwater fever,
and is inclined to agree with Leishman in thinking they may be parasites
of the nature of the chlamydozoa of Prowazek. G. C. Low and C. M.
Wenyon^ criticize the above-mentioned papers, and describe similar
bodies in cells of both the hyaline endothelial types in cases of anaemia
and sleeping sickness, as well as in large numbers in the peritoneal
exudate of a mouse inoculated with Letskmania tropica. They conclude
that the bodies are not related to any particular disease, nor can they
possibly be parasitic in nature. Coles’ appearances they consider
to resemble artefacts more closely than anything else, while they have
never seen them in blackwater-fever cases. Ashburn and Vedder^
describe a spirillum in the blood of a case of blackwater fever.

Treatment. — H. S. Stannus® discusses the treatment of suppression
of urine in blackwater fever, and records a case in which he tried
Incising the Kidney for this condition. Some urine was secreted
through the wound, but the patient succumbed five days later without
having shown any material improvement.

References. — ^Jonr. Royal Army Med. Corps, 1912; ^Jour. Trop. Med.
and Hyg. 1912, 161 ; ’’^Lancet, 1913, ii, 1230; '^Jour. Trop. Aled. and Hyg.
1913, 161 ; ^Bull. Majiila Med. Soc. 1912, 198 ; ^Joiir. Trop. Med, and Hyg.
1913. 131.

BLADDER, DISEASES OF. J. W. Thomson Walker, M.B., F.R.C.S.

Tumours. — Howard A. Kelly and Robert M. Lewis^ give an interest-
ing account of the skiagraphic demonstration of vesical tumours.
This was obtained by introducing into the bladder a suspension of
bismuth subnitrate with gum tragacanth. The bismuth settled at the
base and powdered several large papillomatous growths, so that their
outline and cauliliower-like contour were demonstrated on an .r-ray plate.
In a second case, the bladder was injected Avith 40 c.c. of a 5 per cent
silver iodide emulsion. About half the amount injected was then
voided, and the bladder Avas distended Avith air. The tumour Avas
seen surrounded by a halo of dark shadoAV, and outside this again
Avas a light zone produced by the air.

Chute- thinks that the tardy recognition of bladder tumours is not
often due to lack of symptoms, but to a want of appreciation of their
significance and importance. In a large proportion of cases the early
symptom is bleeding. This occuis in other conditions, and when it is
the only symptom there is a very unfortunate tendency to assume that
it has a less important origin, and to wait and see if it recurs. The
x'ecurrence aauII often not be for Aveeks or months, and again the bleeding
ceases promptly under almost any treatment. It should be clearly
understood by practitioners that any haematuria may be a sign of very
serious bladder disease, and should be looked upon with suspicion
until its source and cause ai*e clearly demonstrated. A very large

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proportion ol bladder tiunoiu's are malignant from the start, in tliat
they inliltrate the bladder wall and lead to mctastases. Some that
are apparently benign at tiie beginning, tend later to infilti'ate ; while
others that do not show any tendency to infiltrate, tend to niultipl}-
and shorten life by hseinorr'hage.

K. O'Neil'^ records observations on his Operative techniqiic in
ten cases of bladder tumour. Suprapubic cystotomy was employed
for the removal of papillomata with small pedicles ndiich did not
involve the ureteric orifices. The patient was placed in the Trendelen-
burg position, and the tumour excised with a margin of normal tissue.
If it were situated near one of the ureteric orifices, a catheter was intro-
duced, the pedicle grasped with a right-angled clamp, and the growth
excised. The wound was closed with continuous catgut suture. The
cystotomy wound was dosed in two layers, a small i libber drain placed
in the prevesical space, and a catheter introduced into the urethra.
In one out of the four cases in which this method was used, the catheter
l:)ecame x^lugged, necessitating reopening of the suprapubic wound,
and a sinus persisted for weeks. Transperitoneal cystotomy was the
operation of choice in all cases of sessile and infiltrating growths, except
those so extensive as to require total cystectomy.

In discussing the results of Operation at the Mayo clinic, 11 , S. Judd‘
slates that 114 cases of primai*}" tumours of the bladder were examined,
the average age being 53*1 years. These tumours rvere classified
accordingho their clinical course into benign and malignant. There were
only two benign cases (fibromyomata) ; all the rest, which include
papilloma and carcinoma, were regarded as malignant. The method
of operative procedure must be determined by the general condition
of the patient and the cystoscopic findings. Arteriosclerosis, renal
insufficiency, myocarditis, etc., are factors contraindicating radical
procedures. Bimanual examination by vagina in the female and by
rectum in the male is most important in the diagnosis, as thus we mar'
be able to determine the piesencc and extent of induration, and cases
will be eliminated in which operation might otherwise be attempted.
The cystoscopic examination is most important, not only in determining
the number, location, and extent of the lesions, but also in helping to
' differentiate a bleeding hypertrophied granulating surface from a true
iieoplasm. When possible, a portion of the growth, large enough for
microscopical examination,’ is excised through the cystoscope. If
there are palpable metastases or considerable induration at the base
of the bladder, the case is considered inoperable. If there is no indura-
tion but a bladder completely filled with growth, the case may still be
operable, since the pedicle may involve a small area only.

One of the chief advantages in the transpeiitoneal operation is that
it affords an opportunity of observing the pelvic lymph-nodes and tlic
abdominal viscera. The prostate is rarely involved except in the late
stages ; should there be any doubt regarding this, however, the gland
should be removed with the tumour. In five cases a prostatcctomv'
was necessary.

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In the 1 14 cases, there were 38 where no operation was done on
account of the general condition, the extent of the disease, or the
refusal of the patient. Thirty patients were submitted to transperi-
toneal operation. Three of these patients died, two on the seventh
and one on the third day after operation. Of the remaining 27
patients, 9 are dead and 17 living, while one is lost sight of. Three
patients are well after five years ; 10 have lived three years, one prob-
ably with recurrence. Of the 17 patients living at present, 4 have
been operated on for recurrences, In one case the entire bladder was
remoi’ed, and the patient is alive without recurrence over two years
later. In 33 cases a suprapubic extraperitoneal operation was chosen
because the tumour was on a pedicle and not infiltrating the wall of
the bladder, or because the patient’s general condition would not
warrant a more radical procedure. One patient died at the end of
three weeks. Four patients are living without any evidence of recur-
rence six years after the operation, while 8 are free from s^nnptoms
three years after operation ; 3 have been treated for recurrence.

[It will be noted that these statistics refer to all tumours of the
bladder with the exception of hbromyoma. They therefore include
tumours which many surgeons classify as non-malignant, and cannot
therefore be compared with statistics of operation either on so-called
simple papilloma or on malignant growths of the bladder. — J. W. T. W.'J

Hartmann'^ x'ecords 47 cases of operation for tumours of the bladder.
With the exception of one case of myoma, which recurred after two
opei'ations and eventually caused death, all the tumours u'ere epithe-
lial neoplasms, papillomata, or carcinomata. There were 15 cases of
non-infiltrating tumours, 2 of which were operated on several times foi
recurrences. The immediate results were good. Two deaths occurred,
both from conditions independent of the operation. Nine cases were
followed, and there were 6 cases of cure lasting fiom three to seven
years, 2 recurrences, and i death. There were 26 cases of infiltrating
tumours, in 9 of which a radical operation — partial cystectomy — was
performed. There was one operation death, one death from pyelo-
nephritis, and two cures lasting five and nine years respectively.
These were cases in which the tumoxir was situated at the summit of
the bladder. In 17 cases a palliative operation only was per form etl,
namely, cystotomy with curettage and cauterization of the tumour.
The operative mortality \vas high.

Edwin Beer,^^ who introduced the method of treatment of papillo-
mata of the urinary bladder with the High-Frequency Current, says it
is unsuitable for malignant growths. For these a transperitoneal opera-
tion alone promises good results. In papillomata, however, the recur-
rences are so frequent (50 per cent) that high-frequency cauterization
should be, used. The author has received replies from 33 surgeons who
have used the method. About 187 cases of vesical papilloma have been
treated in America, and 28 in Eixrope. “Not only are these surgeons
satisfied with the simplicity and immediate results, but they are so
well satisfied with the end result that all are using the method at the

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present time/' The cases he would exclude from this method are:
(t) All papillary carcinomata; (2) All patients that are intolerailt of
cystoscopic examination ; (3) Those few cases that are inaccessible
either with the indirect or wath the direct vision cystoscope, as well as
large growths at the neck of the bladder that bleed severely on the
introduction of the instrument.

Horace Binney^ records his experience of this method in 4 cases.
According to the particular form of coil used, the current applied may
be of the bipolar or d'Arsonval type, or the unipolar or Oudin type.
In the first, one pole is placed in contact with the patient’s trunk or
limb by means of a broad flat electrode, while the other pole is attached
to a pointed metallic electrode placed on the tumour. On closing the
circuit a fine stream of sparks is developed which produces a super-
hcial cauterization. In the second (Oudin) type, one pole only is
necessary. This is connected to a pointed electrode and applied close
to the tumoui, giving off a similar stream of sparks, the return flow of
current passing through the patient, the surrounding objects, and even
the air. The effect of this current on tumour tissue is to produce a
superficial cauterization at the point of contact of the electrode. This
is not fulguration, a term which has been borrowed from the electro-
therapeutists, and designates a wholly different electrical effect. “ High-
frequency cauterization ” is the more exact and, therefore, preferable
term. The electrode is brought in contact with the tumour, and on
closing the circuit the cauterization is begun. It has the effect at first
of blanching the tissue, and after about fifteen seconds the cauterization
actually begins, with charring of the tissue. Carried on for more than
twenty-five or thirty seconds, the cauterization becomes marked,
and the tissue cauterized adheres to the end of the electrode. If
carried on for longer than that difficulty arises through fairly
large masses of tissue sticking to the electrode. Papillomata, even of
considerable size, can be completely destroyed in a reasonable number
of sittings.

Of the cases so far reported there has been no mortality. One case
of sudden death a few days after the treatment is reported by Beer ;
but the patient suffered from cardiac disease, and the treatment
does not appear to have caused death. In suprapubic operations,
haemorrhage, sepsis, and post-operative pneumonia occasionally occur,
although with diminishing frequency, thanks to improved technique.
In high-frequency cauterization there appears to be no danger of
any complication except haemorrhage. In the majority of cases this
is too slight to be of importance. One case of severe haemorrhage is
reported by Keyes ; and the author has had one case of bleeding for
ten hours. The discouraging feature of operation for papilloma is the
tendency to recurrences, or to the development of fresh tumours in other
parts of the bladder. The percentage of recurrence, according to
Rafin, is 26. In papillomata treated by high-frequency cauteriza-
tion, the period of less than three years during which this method has
been under trial is too short to give convincing statistics. In iq

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cases recorded by Beer, Keyes, and Buerger, only one was known
to have relapsed. “ The majority of these cases have been followed
for more than six months.” In 6 cases treated in the Mayo clinic
where a year or more had elapsed, none had recurred.

Calculus . — An important article by Madden*^ deals with the incidence
of stone in Egypt. A popular fallacy, he says, is current, that Egyptian
stones are’ always phosphatic, and therefore soft and friable and easily
crushed, and that they are all secondary to bilharziasis. In the
author’s first 100 cases of operation for stone, although 60 contained
phosphates among other, constituents, there were only 10 purely
phosphatic calculi in the whole series. The majority of stones met
with in Egypt have a nucleus of uric acid or oxalate of lime, and are
originally formed in acid urine. Later the urine becomes alkaline, and
phosphates are deposited on the nucleus. Some of the nuclei contain
bilharzia ova, which were probably tying originally in a broken piece
of bilharzia! papilloma ; and in the earlier stage of bilharziasis there
is no reason why the urine should not remain acid, and the resulting
stone be entirety uric acid or oxalate. The incidence of stone and that
of bilharzia are to some extent independent of each other, the latter
increasing in frequency, while the stone cases remain stationary. The
vegetarian habits of the fellaheen probably contribute very largely to
the formation of stone.

Stone in the kidney forms a very small proportion of cases (i*6 per
cent in 312 cases), and stone in the ureter is very rare. In stone in the
bladder it is quite rare to find the bladder healthy, and in most cases
the classical symptoms of stone are masked by those of bilharziasis.
The operation mortality for stone in the male bladder was 7*8 pCi cent
in 294 cases ; the septic condition of the whole urinary tract in these
cases makes it surprising that the mortalit^r is not larger. “ Lithotrity
must always be the operation of choice for stone in the bladder in
Egypt.” It is the most satisfactory method, and there is less risk of
further septic infection. It is unsuitable for children, and may be
contraindicated by extensive bilharzial lesions of the urethra. A thick
bladder tightly contracted on a large stone necessitates Suprapubic
Lithotomy. There were 9 deaths in the series of 204 lithotrities. ’ In
53 cases of perineal lithotomy there were 4 deaths, and in 28 cases
of suprapubic lithotomy there were 6 deaths.

Arthur T. Cabot’s® opinion is that Litholapaxy is the operation of
choice for the removal of most stones in the bladder. It is surprising
to find the operation imperfectly understood and little practised among
the younger generation of surgeons. Litholapaxy has a mortality of
from 1*6 to 6 per cent, and suprapubic lithotomy a mortality of from
10 to 20 per cent. The convalescence after suprapubic lithotomy is
more painful, and from four to ten times as long as after litholapaxy.
Litholapaxy interferes less with the function of the bladder, and in the
author’s experience of 219 cases of stone removal, there has been more
tendency to recurrence after suprapubic cystotomy than after litho-
lapaxy. Before the introduction of the cystoscope, unsuspected condj-

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lions might sometimes be found on opening the bladder suprapubically,
but tliis statement no longer holds good. The reason why many
surgeons continue to practise suprapubic lithotomy in uncomplicated
cases is, according to the author, that they do not possess the necessary
instruments, and have never taken the trouble to learn the technique
of litholapaxy. The author had performed litholapaxy in 185 cases,
with a mortality of 4-3 per cent, and the whole of the fatal cases could
not be attributed to the operation. In cases of prostatic enlargement
with secondary stone, the obstruction should be removed, and the stone
with it ; these cases were not now subjected to litholapaxy.

In the discussion on this subject at the American Medical Associa-
tion, William E. Lower advocated the use of suprapubic cystotomy
for all cases of vesical calculus. He pointed to the improvement in
the records of suprapubic operations. “ The opportunities for any
one person in this country to acquire a large experience with the.
lithotrite within any reasonable time are vex*y limited.” Stones
might be too large or multiple, might be encysted or adherent,
or the patient might be very young ; and the suprapubic operation
was necessary in all these cases. In piostatic hypertrophy in old men
litholapaxy is contraindicated. The length of convalescence in supra-
pubic operation is reduced by suture of the bladder.

Gussendorf,^® of Jerusalem, relates his experience in closure of the
bladder after suprapubic lithotomy in children. In eight years he
performed suprapubic lithotomy in -40 children under ten years. In
21 cases the bladder was closed, and in 19 drainage was adopted. Of
the 21 cases where the bladder was closed, only ii healed completely
so that it was safe to allow them to go home fourteen days after the
operation. Of the remaining 10 cases, leakage occurred without other
complications in 7, so that the wound did not heal for twelve days
longer. In 3 there were serious general symptoms before the wound
broke down and the urine escaped. In the 19 cases treated by draining,
the average duration of healing was forty-five da^^s, and in 2, secondary
stitching of the bladder was necessaijL The author avoids closure of
the bladder ; (i) In children in good general condition, where there is
pronounced bladder iii'itation not relieved by some days in bed ;
(2) In children in poor general condition, and where there is a raised
temperature or other sign of pyelitis ; (3) In children when the

bladder mucous membrane has lost its elasticity and the stitches cut
out very easily.

Ri^ptiire. — Achlecker^^ discusses the question of uraemia in intraperi-
tonea! rupture of the bladder. If the urine escapes into the peritoneal
cavity, the fate of the patient depends first on whether the urine was
sterile or infected. If there has been C3^stitis, or if infection is earned
by a careless passage of a catheter the peritoneum becomes infected,
and the prognosis is bad. It is laid down as a rule that when theie is a
suspicion that the bladder may have been ruptured, a catheter should
only be passed for diagnosis where it is possible to proceed at once to
laparotomy. Usually the symptoms following intraperitonea 1 rupture

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of the bladder are those of infection rather than of uraemia. The author
records two cases where the symptoms of uraemia completely domi-
nated the clinical picture. When this occurs, he recommends Intra-
venous Saline Infusion, after operation for the closure of the rupture
has been performed.

Dysuria in Women. (See also Urinary Incontinence in Women.)
— David Newman^2 draws attention to certain urinary conditions in
women, associated with frequent or painful micturition, which require
careful examination with the cystoscope for their diagnosis. These
are as follows : (i) Cystitis of pregnancy and its results ; (2) Early
renal tuberculosis ; (3) Early tuberculosis at the base of the bladder ;

(4) Lesions at the neck of the bladder, the trigone, and the urethra ;

(5) Polyps of the urethra ; (6) Movable kidney. In the cystitis of preg-
nancy the symptoms may not be very severe at first, and are attri-
buted by the patients to the pregnancy ; after this is over they are
liable to suffer from bladder irritation, and the disease becomes chronic.
The cystoscopic appearances may be very slight considering the
amount of pain and irritation — merely patchy congestion, without
thickening of the mucous membrane. Usually, however, the mucous
membrane is congested, and covered with thin flakes of mucopurulent
material. Urethritis is a frequent complication. In early renal tuber-
culosis there is frequent micturition without pain ; later there is vesical
irritability with pain and sudden vesical spasm when the bladder has
been distended to a certain degree. The author draws the following
conclusions from his personal experience of cystoscopy in these cases :
When one ureteric orifice is altered, and the other normal, the renal
lesion is on the side of the morbid ureter ; »the deformity of the orifice
and the lesion there indicate the nature of the renal disease ; the
character of the urine escaping from the ureter denotes the morbid
changes in the kidney; the frequency, size, and regularity of the
shoots from the two orifices indicate the functional activity, or the
presence of undue irritation, in the respective kidneys ; when the
orifice of the ureter is strictly normal, no serious disease exists in the
corresponding kidney; when the kidney is normal the orifice of the
ureter is also normal ; when there is evidence of tuberculosis at the
orifice of the ureter, there is always associated with it tuberculosis
of the corresponding kidney ; in tuberculosis of the bladder the ureter
does not become involved if the corresponding kidney is free from
disease.

There is a common form of irritable bladder associated with frequent
micturition during the day, and occasional or persistent incontinence at
night. The urine is liighly acid, and contains mucus, epithelium, and
B. coli ; cystoscopy often shows a congested neck and slight hyper-
lemia of the mucous membrane.

Exclusion of the Bladder. — Charles H. Mayo^** reviews the literature
on this operation, one which has been slowly accepted by the medical
profession, partly owing to a high mortality in the earlier methods, and
partly to sentimental conservatism which urged the preservation of the

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J46

bladder at a.iiy cost, regardless of control or comfort To determine
the best method of disposal of the secretion of the kidneys in indhiduals
in whom it is nccessar}^ or expedient to exclude the bladder is still one
of the serious problems of surgery. To say, however, that the modern
operation exposes the patient to greater danger from infection than is
compensated for by the mitigation of his suffering, together with the
natural mortality of the disease, is not consistent with the history of
recent records of such cases. Unfortunately many patients already
suffer from secondary infective complications before operation is
advised. The operation is indicated for : (i) Patients with congenital
anomalies of the bladder or urethra in which control of the urine cannot
be restored, or painfnl sequelee cannot otlierwisc be relieved ; (a) Those
ill whom portions of the ureter are necessarily or accidentally injured
or removed during abdominal, pelvic, or sacral operations ; (3) Those
in wlio'm malignant disease of the bladder is loo extensive to permit
removal by partial resection while preserving the power of retention
of urine ; aiicl similar cases, or other diseases of the bladder, where the
pow'cr of retention and control add to the suffering.

The various procedures adopted for deeiling with the ureters after
extirpation of the bladder, especially in the treatment of ectopia vesica*,
are reviewed by D. Taddei.^^ He describes an operation which
he has carried out on dogs, by which the csecum is used as a reservoir
for the diverted urine. No changes w^erc found in the epithelium
of the cascal mucous membrane, after a slight initial hyperaemia.

Contracture of the Neck of the Bladder, — Chetwood^'^says, “ Whatever
other cause may exist for the condition of vesical retention outside
of prostatic enlargement and lesions of the central nervous system,
there certainly does exist one in the nature of circular, sphincteric, and
prostatic stenosis, causing incomplete and complete retention of urine.
This appears in the young as w'ell as in the old, may occur independent
of prostatic enlargement or be combined wdth it, is sometimes a hbroid
stenosis, being mostly inflammatory, may be confined entirely to the
internal sphincter or encroach on the prostatic orifice and include a
large i;)ortiou of this section of the urethra, and is amenable to surgical
relief by complete incision, preferably galvano-caustic, or by complete
extirpation.’' The author records the case of a man, 30 years old,
who gradually developed complete retention. There was no prostatic
enlargement. The bladder had been opened siiprapubically, and
contraction of the urethral orifice found which was impassable to the
examining finger. Post mortem it was discovered that the internal
meatus was contracted to the size of a number 18 French catheter,
and was exceedingly rigid. Microscopically the condition was one of
chronic and acute perifollicular inflammation.

Simple Solitary Ulcer. — Buerger^® formulates the following conclu-
sions. Clinical, cystoscopic, and pathological studies in two cases ha\'e
shown conclusively that simple callous ulcer of the bladder can and does
exist. The symptoms are intense dysuria, urgency, frequency of micturi-
tion, hajmaturia, and pyuria. Chronic cystitis and contracted bladder

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are often the outcome. The region of the trigone is the favourite site of
ulceration, and other superficial erosions may be present elsewhere in
tlie bladder. In all cases of vesical ha?maturia a careful search should
be made for the presence of a simple solitary ulcer ; bleeding ulcers
may be overlooked if we fail to bring every portion of the superior and
posterior walls of the bladder into view. In the treatment of this
condition {as well as in the treatment of tuberculous ulcer after nephrec-
tomy), the Fulguration method should be tried ; and if this fails,
Mercurial injection should be given in cases of simple ulcer of the
superficial variety. More recent clinical observations have shown
that there is a type of simple ulcer of the bladder which ma^^ be termed
chronic and callous. Such ulcers should be Excised with the punch
forceps through the operating cystoscope.

References. — ^Surg. Gyti, and Obst. 1913. i> 30S ; '^Bost, Aled, and Snrg.
Join'. 1913, i, 302; ^Ibid. 305; ^Joitr. Ainey. Med. Assoc. 1912, ii, 1788;
^Snrg. Gyn. and Obst. 1913, i, 207, abstr. ; ^Med. Rec. 1913. i, 242, and Jour.
Amev. Med. Assoc. 1912, ii, 1783 ; "^Bost. Med. and Surg. Jour. 1913, ij 3^8 ;
^Lancet, 1912, ii, 132; "’^Jour. Amer. Med. Assoc. 1912, ii, 1954; Mil neb.
med. Woch. 1912, 2S06 ; med. Woch. 1912, 2302 ; "^'Wasg. Med.’Chir.

Jour. 1913, i, 324 ; ^\4nn. Surg. 1913. m 133 ; '^Miev. dc Chir. 1913, 37 : ^^Jour,
Amev. Mc4. Assoc. 1913, i, 257 ; '^^Ibid. 419.

BLASTOMYCOSIS. Herbert French, M.D., F.R.C.P.

Prior to the publication of the classical studies of Schenck and Smith
in 1898, the cutaneous lesions of sporotrichosis were usually ascribed
to syphilis, tuberculosis, or coccic cellulitis, and even to-day the
true nature of the condition is often not recognized. Blastoniycotic
dermatitis seldom simulates either sporotrichosis or syphilis, although
its resemblance to tuberculosis verrucosus cutis is often so close as to
require cultural differentiation. Occasionally, however, even syphilitic
ulcers may be simulated so nearly that the need for cultures being taken
may not strike the observer. This is illustrated by some cases recorded
recently by Sutton.^ The diagnosis was confirmed by the detection
of the blastomyces, whilst the Wassermanii reaction was negative.

Reference. — ^Joiiv. Amer. Med. Assoc. 1913, i 115.

BLOOD, EXAMINATION OF. O. C. Grnncr, M.D.

Cytology. — Remarks on the origin of blood platelets in relation to
the study of the red corpuscles are given by Brockbank,"*- whose views
arc w^ell knowm. Using pepsin solution, he shows that under its
influence haemoglobin goes into solution and then leaves the red cell,
indicating the existence of a structureless protecting material enclosing
the true envelope, which in its turn has linked to it the blood pigment ;
while the material knowm as a blood platelet exists in a cavity in the
interior of the cell. The best review^ of the whole subject is to be found
in a paper by Schilling-Torgau.^

Fragility of the red corpuscles is discussed by Butler^ in full. The
w’Oi'k is mainly confirmatory of that of others. The fragility is
decreased in obstructive jaundice, pneumonia, and chronic tubular
nephritis, whereas it is increased in congenital jaundice and cyanosed

BLOOD EXAMINATION I^j.8 MEDICAL ANNUAL

states. 11 is normal in scarlet fever, cancer, syphilis, pernicious anasmia,
purpiu'a, malaria, etc.

'the coagulation time has been the subject of study by Lee and White,
who use blood drawn from an arm vein with a syringe. The advantages
claimed are that the material does not come in contact with either
tissue or skin, so that absolutely pure blood is obtained. It is doubtful
whether tire apparently simple procedure is justified as a routine one,
although these authors claim that it does no harm to the vein. The
paper gives a list of the conditions under which the coagulation time
varies- Another coagulometer of rather complicated form is described
by Dorrance.^

The diagnostic significance of blood counts in various diseases is
discussed by a number of authors. Smith® finds that the white cell
counts in pelvic suppuration are extremely variable. If the leuco-
cytosis reaches 14,000, there is likely to be trouble during convalescence.

Fiske’ shows that there is no leucocytosis in bone tuberculosis in
children. If such is noted in the blood, it points to some other focus
of infection. The tendency is for the total count to be less than
12,000 in tuberculous cases and over 18,000 in osteomyelitis.

Ward® describes small giant “ cells in the blood of cases of cancer
in which metastases have occurred in the bone. They are about four
times the diameter of .the red blood-cell.

The Arneth count has been studied in tuberculosis of the lungs by
Ringer® and Rayevsky.^® The latter made a careful study of the
various constituents of the differential count, and found that the
eosinophiles were increased except in advanced cases. As regards
lymphocytes, he found that, taking both small and large ones together,
they ran distinctly parallel with the total nuclei in the Arneth count,
and were inversely proportional to the total leucocyte count. An
increase in the transitional cells appeared to indicate an increased
activity of the tuberculous disease. Ringer used the Arneth count
for purposes of prognosis. In most cases it would indicate the patient’s
resisting power, but the method cannot be blindly relied upon.

Lymphocytosis, according to Becker,^^ is a persistent feature of
the blood of children suffering from acetoneemia in attacks related to
digestive disturbance.

Veraguth and Leyderheim^® report the very rapid changes in the
blood count produced by the influence of weak electric currents passing
through the body-

Hazen^® gives an exhaustive study of the leucocytes in syphilis.
The main feature about the blood is the increase of lymphocytes in
secondary syphilis under the influence of treatment. In untreated
cases they are apt to be increased, in negroes and females. The higher
the count the better will be the effect of treatment. This increase of
lymphocytes is shown also in cases of papular eruption. Should there
be a skin eruption with eosinophilia, the diagnosis of syphilis may
be excluded.

Chemistry. — A handy means of estimating the amount of sugar in

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BLOOD EXAMINATION

the biood is given by Bang.^*^ Little pieces of blotting-paper, 16 by
28 mm., are cut out and used to soak up blood taken from the ear before
breakfast, until the paper is quite saturated. This is then placed in
a test-tube, and into it are poured 5 c.c. of boiling salt solution {136
c.c. saturated potassium chloride ; 64 c.c. water, *15 c.c. of 25 per cent
hydrochloric acid). In half an hour the fluid is poured off into a tube,
and 5 drops of Fehling No. 2 and 2 drops of Fehling No. i are added.
After boiling for half a minute, a precipitate is looked for within t^vo
minutes ; if found, it proves an excess of sugar in the blood. This
may be noted in cases of kidney disease, supposing that there is
inadequate excretion of sodium chloride or nitrogen.

The significance of chqlesterin is discussed by Weltmann.^^ A
method for its estimation is given, wherein the colour is collected by
chloroform and roughly determined by comparison with a Fleischl
hsemometer. The ratio between the i*eading on the scale and parts
per thousand of cholesterin has been worked out on a table affording
a very convenient method of estimation. The amount is increased in
arterial and kidney disease, sometimes in liver disease. It is increased
in syphilitic nervous disease ; diminished in tumours associated with
cachexia, and in active tuberculous disease.

Ferments. — (i) Peptid-spliiting. — Smithies^® finds that when aseptic-
ally obtained fresh blood-serum is combined with a solution of glycyl-
tryptophan (Fischer) and incubated under toluol at 37° C. for twent}'--
four hours, on acidulation with 3 per cent acetic acid, typical rose-pink
to violet colour changes occur on the admixture of bromine vapour.
(2) Glycogenic. 2 c.c. of blood are collected into a vessel containing
10 c.c. of glycogen solution {1*5 per cent). The mixture is clarified by
means of two or three drops of soda, incubated for half an hour at
37° C., and two volumes of potassium sulphocyanide are added carefully.
This makes the mixture limpid enough to read in a polarimeter tube ;
the rotary power is then estimated. Glycogen is + 196, while sugar
is 4- 52. GhedinF" found this estimation of value in the study of
liver disease. A diminution of rotary power indicates its presence,
This is more marked in chronic hepatitis, cholelithiasis, and catarrhal
jaundice.

The amount of iron in the blood was found to be in excess of that
which is combined with haemoglobin, to an extent bearing a ratio to
the total amount of iron. According to observations by Fowell,’-'* the
finding of special interest is that the ratio between the two forms of
iron is raised to nearly two to one in cases of pernicious anaemia. It is
normal in cirrhosis of the liver. The method employed is a modifica-
tion of J Giles’.

Opsonic Index . — A strong advocate of opsonic work in cases of
tuberculosis is found in Staveley Dick,^® who claims that the average
obtained by counting 100 cells is very close to the absolute average.
He advocates the use of heated serum (55° to 60°) for ten or fifteen
minutes. Most unheated serum makes several determinations neces-
sary. There is no fixed relation between the improvement of the

BLOOD EXAMINATION

T50

MEDICAL ANNUAL

]iatient under the injliience oC tuberculin and the amount of opsonin
in the blood. The use of the index lies in indicating the amount of
exertion llic patient may undertake, and as a guide to the dosage.

S1':roi.ogy. — Dialysia lest of Abderhaldeu [see also Pregnancy,
Diagnosis of). — This has been disciussed by a very large number of
authors, and its application to the various sections of clinical pathology
appears to be considerably extended. While it is of special service in
the diagnosis of pregnancy, it was quickly applied to the detection of
carcinoma, of disturbances in the thyroid and kidney, of diabetes, and
of various forms of insanity. Indeed, the process appears to present
possibilities of detecting the existence of specific immune substances of
wide range, and so opens up extensive fields of research. The follow-
ing writers may be referred to : Frank, Rosenthal, and Biber stein,
Lampe and Papazolu,-^ Lampe and Fuchs, Abderhalden and Schiff,-'^
and Kabanow.-^ On the other hand, it appears that the Abderhalden
tests are not directly related to the sx:)ecific immune bodies which
appear after parenteral introduction of proteid into the organism.
Frank and Rosenthal proved that some of the proteolytic ferments which
appear in the circulation after parenteral administration of proteins
are of non-specific character, while others may be intensely specific,
the explanation of the paradox being that the method of treatment of
the organism during the process of sensitizing it may determine the
appearance in the circulation of a whole gamut of ferments of specific
and non-specific nature.

The theory of the reaction is as follow's. The cells of the body break
down the products of their metabolism so far that only simple sub-
stances appear in the blood-stream. If the breaking-down is disturbed,
so that more complex derivatives of protein, or cells themselves are
allowed to enter the circulation, the organism reacts by forming specif! c
ferments which can break down this foreign material. The essential
support of this hypothesis was the discovery that in pregnancy there
\\'as a ferment in the blood which could break down placental protein.
Perhaps the greatest prominence has been given to the subject in
connection with the diagnosis of carcinoma.

The method employed for detection of the ferment action consists of
two parts : (i) The so-called optical method, where the rotator^" power
of the blood-serum becomes altered ; and (2) The dialysis test, which
depends on the detection of dialysable products. In thislatter,^^ w^ell-
washed pieces of organ are boiled for five minutes in water to which a
trace of acetic acid has been added. The tissue is wiung out, placed
in more water, and boiled in the same way. The filtrate is tested for,
either by the biuret test or the ninhydrin reaction. If either of these
is negative, the organ is ready for use, and may be preserved in
sterilized water treated with chloroform and covered with toluol.
Into a dialysis thimble No. 579A of Schleicher and Schiill, place 1*5 c.c.
of the serum to be tested and i gram of the organ cut up into pieces
the size of a pea. Suspend into an Erlenmeyer flask containing 20 c.c.
of water, and cover both layers of fluid with toluol. After incubating

NEW TREATMENT 151 BLOOD EXAMINATION

sixteen hours, divide the dialysate into t^vo parts. To lo c.c. of the
first add 2-5 c.c. of 33 per cent soda, and float *5 c.c. of very dilute
copper sulphate solution upon that mixture. A violet ring will appear
at the junction line if the biuret test is positive. To 10 c.c. of the
second, add *2 c.c. of i per cent aqueous ninh^xlrin.*’* Boil exactly one
minute. A blue colour indicates the existence of dialysable break-down
products of protein. The following precautions should be observed:
(i) hlake a control without a piece of organ ; (2) The washing of the
organs must be very precise ; (3) In using extracts of cancer tissue a
very cellular subserate is advisable ; (4) The dialysing thimbles must
be tested to make sure they are impervious to protein and pervious to
peptone.

Epstein*-^ gives a modiheation of the test as used in Freund’s
laboratory. Five c.c. of the dialysate above-named are treated with
‘5 c.c. of 20 per cent soda and 2 c.c. of 16 per cent aqueous solution of
the classical mixture of Fehling’s solutions A and B. Epstein shakes the
mixture afterwards to observe a violet colour, in preference to appty-
ing the ring test. He tested the serum of patients affected with cancer
against cancer proteid and placental proteid, and found that in
practically every case there is a failure to attack both kinds of proteid
simultaneously. Similarly, seventeen out- of eighteen piegnant women
gave a serum which attacked placental proteid and not cancer proteid,
and ever}" one of forty -seven cases which were certainly free from
cancer failed to give a i-eaction.

Rather moie extensive observations were made by Deutsch and
Kohler.^o The reaction iov pregnanc-ywas found positive, whether the
gestation was in or outside the uterus. This conclusion was also
arrived at by the use of the optical method ” by Tschudnowsky.”^"
The alteration in pregnancy at the third month came to about 0*14,
which is the value of the change of polarization.

There are certain resemblances between carcinoma and xDregnancy in
the direction of their serum reactions. Julcbiero, of Turin,-® collected
the following data ; first, that in each the blood-sernm contains greater
anti-tryptic power, and second, that the urine contains an increased
amount of oxyproteid nitrogen and of polypeptid nitrogen. The blood-
serum gives no carcinolytic properties in either, but gives a x^ositivo
Calmette’s activation reaction for cobra \-cnoin Asilh the inactivated
blood-serum. This author used the meiostagmiiic reaction for his
work, finding that the number of di'oj)s that jmssed through the instru-
ment over and above water at 18^ was *8 to 2*.} for prccnancy, whereas
it never exceeded *6 for aii}^ other condition. It was found that
menstruation does not interfere with the positive reaction for pregnancy.
Seventeen out of twenty"-two cases of nephritis had the power of
breaking down renal tissue. Persons with orthostatic albuminuria
failed to give such a i-eaction. Serum in a case of uncmia gave an

*The trade name of the Hoclist chemical works for triketohydrindene-
hydrate,

BLOOD EXAMINATION 152 MEDICAL ANNUAL

intense reaclion with renal tissue, whilst cerebrospinal huid failed to
gi\^e any reaction with it.

Kabanow^‘-^ employed the method for determining the existence of
diseases in the alimentary tract, such as gastric and duodenal ulcer.
For this purpose the mucous membrane of the parts is utilized, and
it was found that an enormous loss of material occurred during the
stages of washing and pouring off the wash -water. It was found
advisable to centrifuge before pouring it off. Another interesting
finding in this work is that in pernicious antemia the small intestine
gives a positive reaction, and indeed the position of an intestinal lesion
may be determined by testing out the serum against each particular
part of the alimentary tract. In this way the test becomes applicable
to the detection of appendicitis, colitis, enteritis, duodenal ulcer, etc.

The work of Lampe and his associates has been directed to the
study of reaction in cases of exophthalmic goitre, and the interesting
observation has been made that a positive I'eaction is obtained, not
only with the normal thyroid extract, but with the ovary, placenta,
and occasionally the thymus gland. This seems to show how valuable
the work would be for determining the existence of derangement of the
internal secretions in the different obscure conditions to which recent
literature suggests their causal relation. It is a matter of theoretical
interest to state that the method was employed to demonstrate the
fact of dysthyroidism in Graves’s disease, although that was already
determinable by micro-mechanical study of tissues. The author sug-
gests that a similar process is taking place in the thymus gland.

Fauser, quoted by Mayer, ^9 applied the test to the domain of mental
diseases, and found that in most cases of dementia prsecox there were
ferments formed which acted against extracts of the pituitary gland
and cerebral cortex. These ferments disappear in the terminal stages
of the disease. Such ferments never appear at all in functional
psychoses, so that here we have a test which promises to be very
important- The observations were based on 250 patients, and are
supported by Wegener, 9 o Fischer and Romer,^i and Neue.^^ a number
of other observers do not get exactly the same results, but here, as in
the test as applied to the examination of cancer cases, it is essential
to recognize that absolute chemical purity must be followed in order
to get reliable actions. The thimbles must be repeatedly tested for
permeability towards peptone and egg-albumen. All the blood must
be removed from the organs, and controls of distilled water must be
used. In dementia praecox there is always a ferment present against
testis or ovary, almost always one for cerebral cortex and for thyroid
gland. There was no serological reaction in any cases of maniacal
depressive insanity. In a case of general paralysis the serum always
reacted positively with cerebral cortex. Two-thirds of the cases of
dementia were positive to testis and thyroid. They all gave a strongly
positive reaction with liver extract. The cerebrospinal fluid entirely
failed to give any reaction. Urstein^^ discusses the question whether
catatonia is to be connected with failure of the reproductive organs to
secrete.

NEW TREATMENT

153

BLOOD-PRESSURE

References.— Chvon, 1913, Sept. 287 ; ^FoUa Hcsmatol 19x2, Oct. :
^Ottari^ Jour. Med. 1913. Jan. 145; ^Amer. Jour. Med. Sci. I9X3> 1. 495 >
Hhid. ii, 562 ; ^Siivg. Gvn. and Obst. 1913, i, 4^3 J "^Bost. Med. and Szirg.
Jour. 1913, X, 606; ^Lancet, 1913, i, 606; ^Amer. Jour. Med. Sci. 1912^ ii,
561; lo.V.y. Med. Jour. 1913, i> S13 ; ^^Miinch. med. Woch. 1913^ 1353 I
'^-Ihid. 22S4 ; ^^Jour. Cuian. Dis. 1913, 618 ; ^-^Munch. med. Woch. 1913*
2277; ^'^Wien. kUn. Woch. 1913, S74 ; ^^Jour. Amer. Med. Assoc. 1912, ii,
539; '^“Gaz. d. Osped 1913, No. 5; ^^Quart. Jour. Med. 19x3, Jan. 179;
^^Pract. 1912, ii, 412; ^^Miinch. med. Woch. 1913. 1594 .' ^^Ibid. 1533 ; ^^Ibid.
2XX2, 2177; ^'^Ihid. 1923; -^Ibid. 2164; -HVien. kin. Woch. 1913. ^ 49 ;
^^Ibid. 1361 ; ^U'liinch. mod. Woch. 1913, 22S2 ; '^HVien. klin. Woch. 1912,
1699 ; ‘^’^MilncJi. med. Woch. 1913. 2044 ; '^^Ibid. 1913. 22 ; '•^^Zeits. /.

d. Ges. Neurol, u. Psych, vol. vii, part 5 : ^^Monats. f. Psych, u. Neurol,
xxxiv, part 2 ; “‘‘Wien. klin. Woch. 1913. 1325-

BLOOD-PRESSURE. {See also Arteriosclfrosig, Nephritis.)

Carey Coombs, M.D., M.R.C.P.

Balard’s^ researches into the arterial pressure during infancy, con-
ducted with the Pachon oscillometer, ^deld little of direct value to the
practitioner ; but it may be worth while to know that at birth it lies
between 35 and 55 mm. Hg, rising steadily with increasing age, and
in parallel, i.e., the maximal and minimal pressures both rise by equal
increments, the pulse-pressure (the difference between maximal and
minimal) remaining constant.

Pachon^ finds that, using his oscillometer, the minimal or diastolic
pressure is of more importance than the maximal or systolic pressure,
and that it ought to be regarded as the standard of arterial tension,
for the following reasons. It is more constant in the same individual
than the maximal pressure ; this latter represents a brief moment
only in the pulse wave ; the minimal pressure expresses the permanent
" charge of blood which the artery has to carry, as well as the
peripheral resistance which the heart has to overcome at the outset
of ventricular systole.

Janeway^ found, by investigation of cases of hypertension seen in
private practice, that the commonest terminal events were cardiac
failure and urccmia, which occurred in approximately equal propor-
tions. The average duration from the time when the patient was
first seen to the date of death was between three and four
years. These observations apply to peisons whose systolic pressure
reached or passed 170 mm. Only fourteen out of a hundred cases
ended in cerebral haemorrhage. His chief deductions from this study
show that the early occurrence of dyspnoea, whether on effort or of the
paroxysmal type, in a patient with high blood-pressure, indicates
marked danger of cardiac insufficiency. Such patients must be treated
as suffering from a cardiac disease, especially by safeguarding methods.
Anginoid pain, even when of marked severity, occurring on exertion
in persons with high blood-pressure, does not make the px'ognosis
worse than do other cardiac symptoms. Of course, every piecaution
must be taken to prevent over-exertion. The majority of these patients
will not die in an anginal paroxysm. Complaint of polyuria, nocturnal
frequency, marked headache, or of visual disturbances, by a patient

BLOOD-PRESSURE

T54

MEDIC AI- ANNUAL

with high blood-pressure, especially if that patient be below ^ift3^
should make the prognosis vety guarded, for ura?mia is a frequent
mode oE termination in such cases.

Treatmicnt.- — Branson^ says that much more might be done to check
hypcr]hesis if patients made periodical visits to the doctor to be over-
liauled, whether they felt symptoms or no. When it has been deter-
mined, by more than one observation, that the pressure is pathologically
high, the cause must be looked for ; and Stott® says it is improper to
exclude renal disease until the new functional tests have been applied
[sec IIenal EFinciENCY). According to this writer, continued Rest in
bed is indicated when the earlier evidences of cardiac embarrassment
begin to be manifest ; but all hyperpietic subjects will benefit by a
regular daily nap after the midday meal, for the pressure falls during
sleep. Cold baths .should be forbidden. The development of any
acute infection — bronchitis, tonsillitis, or even a " common cold'’ — in
a patient with high blood-pressnre cannot be considered a trivial affair,
for an acute nephritis is not an infrequent result. These patients
should be put to bed and carefully watched.

As Mantle*’ and others point out, it is essential to realize that hyper-
tension is often necessary to the maintenance of an effective blood-
supply to the various organs, and that our therapeutic attack should
be made upon the cause. To lower the average pressure by active
means may do actual harm. At the same time, anything in the diet
or habit of life which has a pressure effect should be stopped, or at
any rate limited. Martinet and HeckeB believe that most cardio-
renal patients eat a great deal, a great deal too much, and drink still
more.” They bring forward observations to prove that benefit accrues
from Restriction of the Fluid Intake. The total daily diet did not
include as much as three pints of water in the twenty-four hours.
They regard unrestricted ingestion of fluid as productive of much harm
in persons with high tension.

Allusion is made elsewhere {see X-ray Therapeutics) to a new
method of treatment of which Rostaine® sj)eaks highly. This consists
of X-Ray Applications to that part of the back which corresponds to
the supraienal glands ; it is based on the ” adrenalinremia ” hypothesis,
which attributes high pressure to excessive outpouring of pressor
substances from o\'er-active suprarenals into the circulation. Rostaine
says that this treatment reduced high pressures which were associated
with arterial sclerosis. Many sittings may be necessary.

References. — '^Gaz. cles Hop, 1913, May S ; -Presse MM, 1913, 229 ;
^Jour. Amer. Med. Assoc. 1912, ii, 2106 ; Mancet, 1913, i, 1343 ; ^Med. Rec.
1913, i, 79S ; '^Lancet, 1913. L 1229; "^Presse MM. 1913. 274; ^ISIed. Press
and Circ. 19^3, L 685.

BOTRYOMYCOSIS. Herbert French, M.D., F.R.C.P.

The pathology of botryom^^cosis or telangiectatic granuloma is still
undecided. An illustration of this condition affecting and destroying
a finger was given in the last volume of the Medical Annual;
Plate T" depicts a similar lesion of the nose, from a paper by

PLATE V.

BOTRYOMYCOSI S

[Ihfsiratio/i kindljf lent by the Mnnehener tnedhinlsrhe \ro<.hcnsc'ir//'f.

MEDICAL A XX UAL, IQ14.

NEW TREATMENT I55 BRAIN SURGERY

Konjeizny.^ He regards the cocci which may be found in the tumours
as entirely accidental, and considers the tumours themselves to be
iiccvoid : that is, neevi that have been latent, suddenly taking on
proliferating powers which lead to destruction of the surrounding
tissues but no true malignancy

Heference. — ^Mitnch. med. Wocli, 1912, 2219.

BRAIN, ABSCESS OF. {See also Am(EBiasis, and Otitis Media.)

Geo. L. Richards, M.D.

Berens,^ from his study of 50 cases of frontal lobe abscess, finds the
most constant localizing symptom is hemiplegia. In one case this
was due to the extension of subdural abscess over to the motor area ;
in others, either to the abscess involving the internal capsule, to the
accompanying encephalitis spreading to the internal capsule, or to
pressure of the abscess upon the motor arca.

Reference. — '^Ann. OioL 1913, June.

BRAIN, SURGERY OF. E. IP. Hey Groves, M.S., F.R.C.S.

In the lirst iilacc among all the contributions to this subject during
the past year must be placed the great discussion at the [7th Inter-
national Congress^ on the treatment of cerebral tumours. The most
striking impressions left on the mind by this debate were : the enormous
activity at present being displayed in this field of surgery, Bruns,
Tooth, V. Eiselsberg, Krause, and Cushing each speaking of hundreds
of recent cases ; the pessimism engendered in the minds of expert
onlookers like Tooth, by the attempts at radical removal of malignant
tumours, so that he seemed to advocate the doing of less, rather than
of more, in the direction of thorough operations; and Cushing’s
plea for more careful and slower operations.

Brunsd in opening the discussion, spoke fu*st about the limitations
of the term “ tumour.” Both gummata and tubercle masses were
often to be regartled as such, but the possibility of the disease being
syphilitic ought always to be borne in mind, and a thorough course of
iodides given l^cforc resorting to operative measures. But even if
some improvement did take jdace iiiulcr this regime, gummata of the
motor cortex, by their tendency to scar-formation, Avould usually
require surgical removal.

In the choice between merely palliative and radical operations for
cerebral tumour, he said that the goal of all surgical effoi't should bo
towards removal of brain growths, and that decompression operations
should be reserved for those cases where localization was impossible
or the tumour surgically inaccessible. However, at present the prospect
of success in radical operations is a matter of grave uncertainty,
depending chiefly on three factors : (i) The pathological nature of the
tumour ; (2) The accuracy of diagnosis of the presence and localization
of a tumour; and (3). The accessibility of the tumour to surgical
approach. As regards the first factor, glioma, fibroma, and endothelioma
are usually single, slow -growing, with no tendency to dissemination. The

BRAIN SURGERY 156 MEDICAL ANNUAL

gliomata arc generally ill-clcrmcd and infiltrating, whilst the sarcomata
arc always so. Tubercles and gummata are frequently multiple,
and by no means so favourable for removal as might be imagined. In
the case of tubercle masses, there is great danger of the operative
interference setting up tuberculous meningitis, whilst with gummata
there is often associated a syphilitic disease of the cerebral vessels
which is not to be cured by a removal of the tumour. The method of
Ncisser and Pollack Avas mentioned without any expression of opinion
as to its value. By this procedure, a small piece of the tumour is
removed through a small drill opening in the skull, and from this two
facts may be established : (i) The nature of the growth ; and (2) Its depth
from the surface.

Acenmte localization of the tumour ; as a general rule can be accom-
plished with any confidence only in the motor area, pons, cerebellum,
and hypophysis. Within recent years Bruns has found that in between
70 and 80 per cent of all cases an accurate local diagnosis was possible.

In speaking of the prospects of radical operation and their ultimate
success, he summed up by sa3dng that in 100 of his own cases only
30 were found to be open to radical attack, and of these about 3 or 4
gave lasting cures. If the operative attack was to be limited to a
decompression, this should always include a free incision of the dura
mater.

Tooth's communication^ comprised what is probably the most
valuable and complete analysis of the results of operative treatment of
cerebral tumours that has ever been published. This was derived from
the 497 cases observed at the National Hospital, Queen’s Square, during
the past 10 years. In presenting the table on opposite page, compiled
from Tooth’s statistics, it is necessary to quote his accompanying
remarks : “It cannot be too strongly urged that this table must not
be taken on its face value, but must be judged only after consideration
of the circumstances of all the cases from which it is constructed.
Among the cases which ultimatel}’ died of recurrence, are many positive
surgical successes, some almost brilliant, considering the circumstances,
and followed by relief of pain, improvement in sight and mental state,
and prolongation of life."

In tumours of the frontal region, it is remarked that only one case
of glioma was known to be alive and well some time later. Of the
patients with endotheliomata of this region, 46 per cent died as the
result of operation, a result due to the large size and great vascularity
of these growths, but those survhdng the operation made a lasting
recovery.

In tumours of the central or motor region, the Ioav operative mortality
is as notable as the large proportion of cases that come to operation.
This is readily explained b^^ the fact that their s\nnptoms are so un-
mistakable that the diagnosis is made earlier and with more certaint\’
than in any other region of the brain.

In 33 operations for cerebellar tumour, removal was possible in only
II, and of these only 4 survived for any length of time. In the case

NEW TREATMENT

157

BRAIN SURGERY

of tuberculous masses in the cerebellum, operation often proved fatal
by setting up tuberculous meningitis. In the extra-cerebellar tumours,
of 24 radical operations, 13 died within one month and only 7 survived
for any length of time. But with these cases the symptoms are so
urgent and terrible that something must be done, and the results of
the decompression operations were even worse than those of the radical,
8 out of 12 dying of the operation. As most of these extra-cerebellar
tumours are of benign nature, these bad results seem the more to be

List of 497 Cases, showing Locality of Growth,
Number of Cases operated upon. Nature of Operations,
Fatalities and Ultimate Successes.

Region,

All Cases |

observed. ]

A 1

Opera

No.

ions.

I Reni<

, or c

, No.

val, pa
omple

^■5 0

rtial

c „•

Explora-

tory.

1 -=-^
No. il-S 0

r^:

Decom-

pressive.

No. sell
! ^

Frontal

' 31

1 5

‘ 7

Central

S 3

1 30

i ^

Temporal

! 7

! I

Occipital

5 ^

i ^

: 0

Corona radiata

1 I

Pituitary . .

i 4

—

' —

—

Cerebellum

: 74

, 5

Extrti -cerebellar .

1 44

1 24

j I

: 7

Pons

i 41

. —

—

! I

I 0

Lateral ventricle .

; 2

Optic thalamus

1 I

Mesencephalon

1 j

Pineal

! I !

0 i

: 7

Fourth ventricle .

Medulla

Base

: 4 :

Not localized

1 40

1 5

1 ^

i ’

—

— j

i I

1 —

Totals

* 497

1 2G5

j III

i 74

j 25

N.U, — The figurui. under the heading “ Alive and well’* include those cases which sent no reply
to the most recent enciuiry, Verj much greater detail is given in the original article.

deplored. It would seem that they arise from the effect of the sudden
alteration of pressure upon the adjacent vital centres in the medulla.

The genera] conclusions that Tooth comes to as the result of his
careful survey of the subject may be summarized as follows : That
operations for cerebral tumours have a high mortality, whoever is the
operator and whatever the operation. This mortality is lowest in the
central region and highest in the extra-cerebellar. The dangers are
shock, cardiac or respiratory failure, which may come on suddenly as late
as fourteen days after the operation, and sepsis. In considering the

BRAIN SURC5ERY

MKDICAL ANNUAL

a|)pn.reully successl'ul cases, it. is to be noted that survival often occurs
without improvement c\'cn alter radical treatment ; but on the other
hand, the ]:>alliati\ e operation often relieves the symptoms, especially
oj)tic neuritis. As to the choice of operation, results would be much
better if the malignant growths (i.e., carcinoma, sarcoma, and many
gliomata) were left absolutely alone. Often an apparently successful
operation on such a case seems to stir up an increased malignancy.
If when the vSkull and dui'a have been opened freely, there is no tumour
apparent to sight or touch, exploration of the brain is to be deprecated.
It is remarkable what good results often occur after the first stage of a
two-stage operation. This would suggest that it is always worth while
to wait after this first stage until the improvement ceases, in order to
give a longer time for readjustment of the brain to altered pressure
conditions. In those urgent cases in which the symptoms all develop
within six months, it is probably useless to attempt anything but a
decompressive operation.

gr-rr a *c: gr5 i L7i:eT ■ ■airsi: uru c -Xi-T:. ; -!: a

Fi\q. 10. — Hudson’s appliance for drainage in upeiatiun for liMlroccpl)aliis ; (ti) Sijvei-
M iredmiiiagc mat ; Perniapent drainage lube of coiled silver wiie, \\ith lixatiun vires:

<t } Urain-puncturing tube withidull round end, marked in (iiuuier-inch line.s.

Oppenheim and Kx'ause'^ give an account of the diagnosis and treat-
ment of a small tumour of the vermiform process of the cerebellum
wdiich is a brilliant example of what is sometimes possible in this field.
The tumour was about the size of a w'alniit, and after its removal, the
floor of the fourth ventricle lay exposed to vie\v. The patient, an
unmarried woman of 30, made a good recovery and was cured of her
symptoms.

I V Hudson-^ returns to the subject of the methods of attacking tumours
and dealing with hcemorrhage of the brain. He relates a successful
case in which he removed the clots from a man of 45 wdth apoplexy.
The important principles to be observed, according to this author,
in all cases \vhere there is a great increase of intracranial pressure arc :
(1) The making of such a large osteoplastic flap as to alloxv displacement
of a large part of the brain in the relief of pressure, without forcing a
part of the cortex into a small hole; (2) The cutting of the cranium
by^ means of strong cutting forceps, which avoids the jarring and \*ibra-
tion that accompany the use of saws or chisels.

NEW TREATMENT

159

BRAIN SURGERY

The same author^ has devised a special technique for the treatment
•of internal hydrocephalus (Fig, 10). He exposes the right temporal
fossa by splitting the muscle, and opens the skull by a burr ; then the
dura is opened and the ventricle punctured. A permanent drainage
tube made of silver wire coil is inserted through the same track, and
its outer end attached to a little radiating silver wire mat (Fig, 10 a, b)
which is tucked into place under the muscle and the skin incision
closed. Haynes® reviews the many methods which have been
suggested from time to time for the relief of hydrocephalus, and adds
yet another to the already formidable list. His proposal is to sew^ in a
fine drainage tube as an anastomosing channel between the superior
longitudinal sinus or occipital sinus and the cisterna magna, (Fig. 11.)

/'VV- II — Hajiifn' uperaiitMJ foi internal liytirocepljaluh ; (n) llic in( isioii has liecn niadi-
into the ci&terna niagna. the needle and Miluie pidled throuch, and the Uil>e sliown ready to
he parsed into the incision ; {/■) The tube has been passed the cisterna tnagna and tin’
siuiire is ready to be tied : (c) ']Tie operation of inserting the tube is shown ronipleled. One
end lies in tlie cisterna magna and the other in the longiuidinal sinus. The bone detritus
may be packed into the gap and tlie skin tightly sutuicd.

The Surgical Treatment of Jipilepsy . — There is no sulqect in cerebral
surgery more dillicult than that of the prospect of relief of epilepsy by
surgical means. From time to time some of the greatest of surgeons
have declared that surgery can relieve even the idiopathic type, but
this is distinctly contrary to the opinion of most. And there are not
wanting those who doubt that surgery can do anything for ev^en the
Jacksonian epilepsy which follows trauma. The generality of tlie
profession stand between these two extremes of optimism and
pessimism. Therefore the careful work of Matthci," in which he has
collected and abstracted all the cases of traumatic epilepsy which are
published, is to be welcomed as being a reliable guide both for treatment
and prognosis. He considers that there arc three distinct etiological
factors in all cases of traumatic epilepsy, viz., hereditary predisposition,

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MEDICAL ANNUAL

injury, and the inflammatory changes directly or indirectly due to the
injury. His collected cases of epilepsy following trauma comprise
326, of which 266 were distinctly Jacksonian and 66 of general type.
The results of the operations in these cases were as follows : —

Cure or lasting betterment of over a year
J acksonian
General

Bad result, death or aggravation
Jacksonian
General . .

Cases observed longer than 5 years as well
Jacksonian
General . .

Death resulted from the operation in

96 ~ 29*5 per cent.
81 == 30*4

15 = 25

Si = 247
59 = 22*2
22 = 36*6 „

24 = 7*4
21 =- 7*9
3=5
19 = 5*7

The operation findings in most cases were nothing, and this was
notably the fact in those where no relief was afforded. In less than
half the number were found bone splinters, depression or thickening
of the inner table, thickening and adhesions of the dura, and cysts of
the arachnoid. In many cases where nothing was found, the convolu-
tions associated with the chief convulsions were removed, with varying
success. It is important that as a preliminary, the affected convolutions
should be identified by means of electrical stimuli.

The chief factor in determining a successful result from the operation,
is the definiteness of the gross change found under the skull. A
definite gross lesion was found in 23 out of 24 of the lasting cures.
The patients between twenty and thirty gave the largest proportion of
successes. The final conclusions are that a more thorough prophylaxis
of traumatic epilepsy ought to be pursued, by trephining all cases of
cranial injury in which there was a likelihood of cortical injury; and
that in cases where epilepsy has developed, the indications for opera-
tive attack are : failure of internal treatment, the directness of the
relation of the epilepsy to the injury, and the Jacksonian type of the
disease.

References. — '^Reports of I'jth Internai. Med. Congr. Sect, vii, 191 ;
^Ibid. 202; ^Berl. klin. Woch. 1913, 333; ^Ann. Surg. 1913, i, 492; ^Ibid.
338; ^Ibid. 449 ; Zeit. f. Chir. 1913, cxxiii, 417.

BREAST, CANCER OF. Priestley Leech, M.D., F.R.C.S.

Those surgeons who follow closely the statistics of cure after
operations for cancer, will have come to the conclusion that the more
carefully these are compiled, and the longer the cases of supposed cure
are traced, the less is the percentage of those remaining free from
recurrence. The reasons for this are many. In the first place, there
is the difficulty of diagnosis until the disease is far advanced ; patients
delay seeking advice, and in the case of the breast, in many text-books
the signs given of cancer are not those of an early stage ; but what is
an early stage ? The surgeon may find the axillary glands enlarged,
though the original disease is a small nodule in the breast which could
probably not be found at all by the patient, and only with difficulty by

NEW TREATMENT

BREAST, CANCER OF

l6l

the surgeon. Even if the patient comes with an easily discoverable
lump in the breast immediately on noticing it, there may be already
advanced infection of the glands.

Spencer Brown^ says his record of operations on cancer of the
breast shows that the fight against cancer so far has been a losing
one. His results may be less favourable than those of others, but they
are honest. He has operated on 131 cases, and has traced the .post-
operative history in 85 ; there was recurrence in 6 cases within
a year, in 46 within two years, in 22 within three years, and recurrence
in 10 within five years ; i patient was alive after fifteen years. These
figures are very discouraging if we are only considering complete cure
as the ultimate goal ; but every day of life prolonged must be taken
into account. He thinks that early diagnosis in a pathological sense
is very rarely made, and that all cancers when operated on are really
advanced. If the theory of Cohnheim, Ribbert, and Beard is correct,
the small tumour represents a late rather than an early development.
He thinks it is the resistance of the patient rather than the virulence
of the cancer, which determines whether the patient shall succumb
early or late.

Primrose, 2 of Toronto, thinks that a “ quick ” section of a suspected
tumour in tiie theatre, if positive, is of the greatest importance ; but
if a negative is given as to its malignancy, it is of comparatively little
import and ma.y be misleading. He gives the particulars of 323 cases,
of which 216 were malignant. He thinks practitioners wait too long
for the obvious signs of malignancy (pain, involvement of the skin,
retraction of the nipple, and easily palpable glands in the axilla)
before sending the patient to the surgeon. The glands in the axilla
are involved at a very early date, and no matter how early operation
is done, it is rare for the pathologist not to find cancer in them. In his
cases, enlarged glands were noted in 36 per cent, but these ought to be
found more often clinically. From an enquiry, he found that in his
own cases the disease had been noticed for a year in nearly 50 per cent.

Beaver, 3 of Philadelphia, reviews 534 operations on the mammary
gland. The primary mortality is low, but the end cures are smaller
than is generally thought. He concludes his article as follows :

“ Approximately, one patient in five is permanently relieved of the
disease b}^ the radical operation, though it must be confessed that the
inability to secure reliable data makes even this percentage question-
able. . . . When popular opinion demands immediate operation on
.the discovery of a lump in the breast, when physicians are taught
to think of breast tumours in terms of operability, and when mis-
^^••^hided humanitarianism no longer ' prompts the surgeon to attempt
injudicious operations, the present lack of faith in the surgery of this
disease will give way to a healthy optimism. ''

Lucas^ reports a case in which he operated on a recurrent cancer in
both breasts in a woman, aged 67, who died , free from recurrence at
the age of 82, fifteen years later. This illustrates the benefit which
is derived from an extensive operation.

BREAST, CANCER OF

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MEDICAL ANNUAL

Halsted'^ has made some modifications in the incisions for removal
of the cancerous breast. He now omits the triangular flap which
covered up the axilla, as it sometimes sloughed. The cut down the
arm is omitted, and often the vertical cut to the clavicle. Not
infrequently the only incision of the skin is the circular one surrounding
the tumour. The skin of the outer flap between the two vertical
incisions is utilized primarily to co%’'er the vessels of the axilla completely
' and redundantly without any tension whatever. The edge of the flap
is stitched by interrupted buried sutures of very fine silk to the fascia
■just below the first rib, in such a way that the skin partly envelops
the large vessels. The rest of the w^ound is covered with Thiersch skin
grafts. The arm is abducted to 90 degrees or more during the stitching
of the wound (Plates VI, Vll). Movements of the arm as free as possible
are encouraged after the second day. The advantages of skin grafts
arc as follows : An unlimited amount of skin can be removed ; skin
grafts present a definite obstacle to the dissemination of carcinomatous
metastases ; recurrences in the deeper planes may be promptly detected
under the thin, grafted skin (these should be burnt away, down to the
pleura if necessary, with the actual cautery) ; the inner or thoracic
wall of the axilla being lined to the extreme apex with grafts, the skin
of the outer flap may be utilized, in redundant fashion, for covering
the axillary vessels, for obliterating the subclavian dead space, and for
elevating the axillary fornix.

References. — Med. Jour. 1912, ii, 949; ^Amer. Jour. Med. Sci.
1913] i, 100; ^Jotiv. Amer. Med. Assoc. 1913, i, 798 ; ^Lancet, 1912, ii, 1644;
^Jour. Amer. Med. Assoc. 1913, i, 416,

BRONCHIAL GLANDS, TUBERCULOSIS OF. (5^^ also Tcberculosis
IN Children ; Tuberculosis, Pulmonary.)

J. J. Perkins, M.B., F.R.C.P.

All are agreed as to the importance of the early diagnosis of enlarge-
ment of the bronchial glands, because here is the first site of tubercu-
lous invasion in childhood. Though some two dozen signs and
symptoms have, according to Zabel,^ been suggested for their detection ,
conclusions which are generally accepted are far from being attained.
The subjective symptoms which are common at the outset of the
invasion of these glands, though important as suggestive of the lesion
in childhood, are by no means distinctive. Zabel mentions catarrh,
pyrexia, especially after exercise, asthenia, tachycardia, cough, pain,
dysphagia, and dyspnoea in this list. A dry, irritative cough due to
pressure of the glands is present in 80 per cent of the cases, and precedes
any demonstrable swelling. In its character it may recall so strikingly
the cough of whooping-cough that it may be impossible to distinguish
between the two. Any attempt to swallow with the head thrown
back is especially apt to provoke it. Dysphagia was seen by Zabel
once only. The pressure of the glandular masses on vessels and
bronchi may cause symptoms ; but these are rare, partly because the
swelling does not usually reach the necessary magnitude, and also

itli 'rhieroch

BREAST

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163

BRONCHIAL GLANDS

because the inferior tracheo -bronchial glands, which are not in a
position to exercise pressure, are usually attacked. Enlargement oi
the superhcial veins, difference between the pulses, and laryngeal
paralysis from pressure on the recurrent laryngeal nerve, occasionally
occur, but cannot be expected.

Turning to direct objective symptoms, we are on much surer ground.
Radioscopy gives invaluable results ; but Zabel warns us that though
calcihed and caseous glands are easily recognizable, the stage of
tuberculous infiltration is not always demonstrable. Moreover, these
old enlarged glands are not necessarily an evidence of active disease ;
they are not rarely to be found in healthy individuals, though in child-
hood their presence is very suspicious and may be taken as an evidence
of existing tuberculosis. Percussion of the thoracic wall gives results
only in tumours of large size, but percussion over the spinous processes
is much more valuable. According to Koranyi, enlarged bronchial
glands give diminished resonance over the fifth and sixth tl\oracic
spines, with an increased sense of resistance. In children, dullness
is found over the third dorsal vertebra, and positive results are obtained
by this means in 40 per cent of the cases.

A iisciiltatioii 0} the voice or whisper over the vertebral spines, the method
introduced by D’Espine and referred to in previous issues of the
Medical Annual, is, according to Zabel and others, by far the most
reliable sign of the presence of enlarged bronchial glands ; it is nearly
always present, certain in its results, and simple to carry out. In fact,
he and many other observers speak of it in the highest terms. The
ear or bell of a stethoscope is applied over the vertebral spines from the
seventh cervical spine downwards while the child speaks or whispers
some word like “ thirty-three.** The tracheal quality of the voice
ceases suddenly at the seventh cervical vertebra in healthy children,
but where enlarged glands are present it can be heard below this point
for a varying distance — even as far as the fifth dorsal vertebra. The
enlarged gland filling up the intervening space between the trachea
and the vertebi*al column acts as a conductor. The presence of the
tracheal quality is the point to be observed, and must be distinguished
carefully from a mere loud conduction of the ordinary tone. Zabel
gives the limits at which the ti'acheal tone is to be considered pathogno-
monic in young children at the seventh cervical vertebra ; in children
of eight years at the first dorsal ; of twelve at the second dorsal ; and
in children of fifteen at the third dorsal vertebra, corresponding to the
natural descent with advancing years of the bifurcation of the trachea,
in the fork of which the enlarged glands lie. Zabel and many others _
give D’Espine’s sign the first place in the diagnosis of the enlarged
bronchial glands of childhood, not even excluding >r-rays from this
comparison. He has found and proved it positive even when radio-
graphy failed.

Reference. — ^Miinch. med. Woch. 1912, 2064.

BRONCHITIS

164

MEDICAL ANNUAL

BRONCHITIS. J. 7. Perkins, M,B., F.R.C.P.

Treatment. — Arneth^ is a strong advocate of reliance on Wfechanical
Measures in the bronchitis and bronchopneumonia of early childhood,
as he has found all the drugs in vogue of comparatively little value.
He insists strongly upon the advantages of Change of Position from
side to side, or even upon the face, according to the site of the lesion,
unilateral or bilateral, with the view of preventing inaction of the
lung and consequent collapse. Packs and tight compresses he
views with disfavour, because of the compression they exert on the
thoracic wall. Dealing with measures for reducing the tempera-
ture, he points out that the internal temperature may be very
high though the surface is cold, pallid, or cyahosed. He has been
compelled to discard the usual procedure of lowering the temperature
in such cases by cool baths or applications, on the ground that it does
more harm than good, the loss of heat being too much for feeble,
devitalized children. He is convinced that the same end can be
reached far better by the use of Hot Baths, which he recommends most
strongly. These equalize the circulation, and by distributing the
blood equally over the body have the beneficial effect required, with
little or no loss of heat, though a slight fall of temperature occurs
in most cases, half an hour to an hour afterwards. The internal
temperature, however, falls several degrees as a rule. This form
of treatment was first advocated among the Japanese, and is a
recent introduction to the Western world. In Japan, for example hot
baths (44® C.) have been recommended for the treatment of croupous
pneumonia, side by side with the colder applications to which we
are accustomed. As regards hot baths in childhood, their use can
now be supported by a number of excellent names ; Baelz, for
example, speaks of their employment in capillary bronchitis as almost
specific. The temperature is really hot, 39° or 40® C. to 43® C. ; the
duration of the bath is five to ten minutes, and the temperature of
the water must be kept up during that time. The effect of the bath
as seen in well -nourished children is that in two to three minutes the
skin reddens, in six to seven minutes the head becomes red and beads
of perspiration gather, and after a few more minutes the extremities
and whole body become very red. The effect of this hypersemia is
seen in deeper breathing, while expectoration is stimulated and fever
lowered. No ill-effect on the heart has been noticed by Ameth even
in weak infants. To increase the effect on the lung, the hot bath may
be followed by cold douching. The child is lifted out of the bath and
cold water quickly douched for a few seconds only on the neck and
breast ; the child gasps, all the auxiliary muscles are called into play,
and the effect on the breathing is described as colossal. The child is
then dried, clothed in warm things, and put into a hot bed.

In conditions of very high fever the bath is repeated as occasion
seems to demand, but of course with great care. The temperature of
40® C., however, is not considered a contraindication. With fever at
3Q® C., the baths as mentioned are given for five to ten minutes, three

NEW TREATMENT

165

BRONCHITIS

times a day, in the early morning, at midday, and in the evening. The
conditions specially calling for this treatment are collapse, cyanosis,
and severe dyspnea ; in fact, the worse the peripheral circulation
and the weaker the child, the more is the hot bath called for rather
than the cold. The children are stated to like these extremely hot
baths ; their mental condition is improved, they become more lively
and sleep well, their appetite is increased, and the diminution in
weight and strength so frequently seen in protracted fever is checked,
in addition to the beneficial effect on breathing and expectoration
mentioned above. Duiing convalescence, Ameth advises the continu-
ance of the hot bath once or twice daily.

Pirie- contributes the results of treatment by Yaccines in a number
of obstinate cases of chronic bronchitis and bronchitis with asthma.
All wexe cases of some standing, in which other forms of treatment had
been employed with more or less w'ant of success ; only those were
included in which the results of treatment had been under observation
for some time. Autogenous vaccines were administered in all instances,
and nothing more remote than the first subcultures of the original
organisms were employed. The dosage varied considerably, but the
general principle followed was to increase the amount until a dose
was arrived at which produced some definite reaction in the shape of
general discomfort, slight fever, and not infrequently temporary
increase in the amount of the expectoration. Treatment should be
pursued on these lines for a considerable time, at least several months.
Of 16 cases treated for bronchitis, 7 might be considered as practi-
cally cured, in 4 there has been marked improvement, in 4 slight
improvement, while 1 was not improved.

A typical case was that of a woman, aged 22, who suffered from chronic
bronchial catarrh so severe at times as to amount to actual bronchopneumonia.
Treatment was continued for a year, and the report a year later is that there
had been complete freedom from bronchial attacks : there were still some
moist sounds in the chest, but not enough to cause anj" serious trouble.

Almost equally good results were obtained in cases of asthma
supervening on chronic bronchitis ; of 9 cases, 2 could be regarded as
practically cured and free from asthma, 5 w^ere considerably improved,
I slightly improved, and i not benefited.

Gillette also insists upon the importance of autogenous vaccines
alone being used, and on the importance of avoiding subcultuiing,
which has been said to impair the efficiency of the vaccine. The dose
in his practice was pushed until some reaction had been obtained,
either general or local, on the ground that a course of small doses where
reactions have not occurred may be ineffective in producing immunity.

An excellent example of the success obtained is seen in the case of a woman,
aged 65, who had a bad attack of influenza seventeen years before. Ever
since that attac c she suffered from a chronic cough bringing up about 2 oz.
of phlegm daily. At the time of the commencement of treatment she was
unable to lie flat at night, and after four injections was able to do so. The
cough and sputum had ceased at the end of five weeks, and though later on
she began again to bring up a little sputum, the cough and expectoration

BRONCHITIS

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MEDICAL ANNUAL

completely disappeared alter three further injections. In another case, a
woman, aged 35, had suffered from bronchial asthma for fifteen months.
1'hough able to get about, she was very short of breath, and frequently had
attacks of dyspncea at night. Treatment by vaccines was continued for
lour months with complete success ; the patient was soon able to lie down at
night, and sleep through to the morning ; the amount of sputum was reduced
from S oz. daily to I dr., the asthma completely disappeared, and the patient
could even go upstairs without shortness of breath.

Campbell^ insists that the liability of stout people to bronchitis is
largely due to the endogenous formation of poisons which produce
inflammation of the respiratory passages, and to the sluggishness of
the blood-flow through the bronchial mucous membrane. The chief
factor in treatment of a stout bronchitic, therefore, is the Reduction of
Weight, He does not take exercise because he gets out of breath so
easily, and the lack of exercise makes him stouter still. In the acute
attack, CampbeH’s first step is to get the patient plenty of cool, fresh
air to breathe, by wheeling his bed or his chair to the open window.
He allows Oxygen also, applies Leeches over the liver, gives Calomel
gr. 5, and Carbonate of Ammonia. As regards Food, he would in all
cases of this kind withhold it altogether for a few days at least. In
liis own words, “ in all cases of acute dyspnoea, starve the patient,’'
and in this there need be no fear of any ill results. Every particle
of food, he says, which is absorbed into the blood and not laid down
as tissue or got rid of as albumin or sugar, causes an immediate increase
in the production of carbonic acid, the excess of which in the blood
is the essential cause of the dyspnoea. To satisfy the patient, a little
beef-tea, or a small portion of minced underdone lean meat, may be
given ; as regards drink, as much water as the patient likes, or weak
China tea, but little or no alcohol. He finds the same factors at the
root of the chronic bronchitis of the obese. Pure, dry, and if possible
warm air is the first essential. For the second object, the reduction of
weight, he has recourse to diabetic diet, i.e., the elimination of starch
and sugar, and prescribes a good amount of Exercise. A regular
aperient is given every night (Paraffin, or Hyd. c. Greta, i gr.,with
01, Ricini i dr.) and the ordinary Alkaline Expectorants, though the
latter play but a secondary part. The concluding words of the writer
are excellent : There is a danger that, as we become more scientific,
we may neglect the moi'e prosaic dictates of common sense and neglect
the obvious ; more can be done for the obese bronchitic by reducing
his weight, tending his digestion, and regulating his exercise, than by
any other measures, scientific or otherwise.”

References. — ’^De-ut. med. Woch. 1913, 1868 ; Med, Joitv. I9i3>

i, 1268 ; ^Ibid, 2S7 ; ^CUn. Jour. 1912, Oct., 33.

BRONCHOSCOPY. {See also GEsophagus.)

W. G. Porter, M.B., F.R.C.S.

Chevalier Jackson, in his report to the International Medical Congress,
said he had addressed enquiries to 380 larjmgologists in America, of
whom only 79 had attempted bronckoscopic or cesophagoscopic foreign-
bod}^ work, and only 35 cared to do it. As regards mortality, in 171

NEW TREATMENT

167

BRONCHOSCOPY

cases of foreign body in trachea and bronchi bronchoscoped during
the last two years by various operators, there were 9 deaths (5*3 per
cent), and in 156 the body was removed. The author’s own statistics,
which are not included above, are as follows : in the last 182 consecu-
tive cases of bronchoscopy for foreign body, there were 3 deaths (1*7
per cent) from any cause whatever within one month. The foreign
body w^as removed in 177 cases.

Of 193 cases of oesophagoscopy for foreign body by various operators,
the foreign body was removed in 155 ; of the 38 not removed, 26 went

/ig. 12.— Illustrating the position of the caliper-guitle in getting the adjustments by which
the point of the bronchoscope can lie brought at operation in close proximity to a foreign
body. For use in case of small foieign bodies in minute bronchi. hy D)\ John

ir. Boyci’.

down. There were 12 deaths (7*8 per cent). Tn 7 of the deaths the
oesophagoscopy was done by operators whose total number of cases
was less than 3. In the large clinics the mortality was 3 per cent.
Of 206 cases of the author’s the foreign body was removed in 198 and
escaped downwards in 8. There were 4 deaths, 3 in patients admitted
with severe lacerations from previous attempts at oesophagoscopy.

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MEDICAL ANNUAL

Excellent progress has been made in the radiographic localization of
foreign bodies, especially now that practically instantaneous radio-
graphs can be taken. The improvement in lateral radiography of the
thorax has been of great aid in the localization of foreign bodies m con-
junction with the caliper guide suggested by Dr. Boyce {Fig. 12) and
developed by the author. This will bring the point of the bronchoscope
in close relation with the foreign body. It is used only in the case
of small foreign bodies which have fallen into a very small bronchus
far down or far out near the periphery of the lungs. Another aid in
this class of difficult case has been used by the author. A positive
transparent film of the tracheo-bronchial tree {Figs, 13, 14) is laid over

13 * — Illustration of a positive film used for overlayinjg to assist in localization of
foreign bodies or lesions in the thorax. The lower white line (i>,i>) corresponds to the
diaphragm, the middle line (p, D) to the dome of the pleura. These lines asswt in placing
the overlay. The upper line (v, c), corresponding to thevo< al cords, is occasionally useful.
Twelve photogra..htc enlargements are on hand, so that a film of the size (rather than the
age) is available for any sized patient.

the negative of the patient, showing the foreign body, when the latter
will show through the transparent tracheo-bronchial tree of the over-
lying positive film. There are twelve sizes of film positives, from
which one to correspond to the size of the patient's negative is
selected.

In the statistics which the author gathered, there was practically
no difference in the mortality or the percentage of successful removals
of foreign bodies between the different kinds of instrimients ; far more

NEW TREATMENT

BRONCHOSCOPY

169

depends on the individual skill of the operator, and doubtless the best
instrument for each man is the one with which he has practised most.

The author insists that the pvepavation of the patient should be the
same as for an^^ operative procedure, by a cathartic, rest in bed, with
cleansing of the mouth by numerous brushings of the teeth and rinsings
with 30 per cent alcohol. For adults the sitting position is very
satisfactory for diagnosis. For infants and children the dorsal position
is better because of better control of the patient. In foreign body
cases, whether adults or children, the patient should always be recum-
bent. This is especially true of foreign bodies in the larynx and
pharynx, which should never be touched unless__the patient is in the
Trendelenberg position.

Fig. 14. —Illustrating a positive radiograijh of the tra« heo-bronchial tree used as a film for
overlaj^ing to assist in localization of a foreign body. The left-hand illustration shows the
film laid over a negative of a patient in whose left main bronchus was a pin. Localization
verified by bronchoscopy. The shadow of the pin is strengthened with ink.

The author’s remarks on ancBsthesia are of especial interest and
importance, and are contrary to what has been the custom in this
country. He states that recent progress in anaesthesia is towards
the use of no anaesthetic at all. After a short period of tubal contact
in bronchoscopy, coughing lessens and often practically ceases, especially
in infants, without any anaesthetic having been used. The author’s
views are as follows : ( i) In children under six, no anaesthetic, general or
local, should be used for direct laryngoscopy, per -oral bronchoscopy,
or oesophagoscopy, except that general anaesthesia may be advisable
in the case of very sharp foreign bodies. (2) In adults, no anaesthesia,
general or local, is necessary for oesophagoscopy, for diagnosis or for
foreign bodies, save in the case of very sharp or large ones. Local
anaesthesia of the oesophagus is unnecessary. For bronchoscopy for
diagnosis, anaesthesia of the larynx, including the epiglottis, is needed.
In the last 107 bronchoscopies and oesophagoscopies for foreign bodies
in children under six years of age done in the author's clinic, no
anaesthetic, general or local, has been used.

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Indications for Bronchoscopy . — ^The author enumerates the following :
(i) The appearance in the radiograph of a foreign body or any suspicious
shadow ; (2) A clear history of the patient having choked on a foreign
body, which has not been afterwards found ; (3) Signs of stenosis of
the trachea or a bronchus ; (4) Signs of pulmonary tuberculosis in
which the bacilli cannot be found in the sputum, and especially if the
physical signs are at the base, particularly the right base ; and above
all if there are physical signs of pleural effusion, even if there be no
history of a foreign body ; (5) All cases of bronchiectasis should be

bronchoscoped for foreign
bodies, and also for local
treatment ; (6) Dyspnoea,

except of course in pneumonia
and similar well-understood
conditions ; (7) Dyspnoea

which tracheotomy has failed
to relieve : (8) All cases of

haemoptysis not definitely
proved to be tuberculous ;
(9) Paralysis of the recurrent
nerve, the cause of which is
not positively known ; (lo)
Thoracic disease in which
any element of doubt exists.
In case of doubt as to whether
bronchoscopy should be done
or not, it should always be
done.

As regards post-broncho-
scopic subglottic oedema, the
author believes this is due in
many cases to rough manipulation and to the introduction of
tubes which are too large for the infant larynx ; in other cases,
the supposed subglottic oedema is really due to the accumulation
of secretions, and can be relieved by the passage of the tube ;
and he especially urges that all cases of post-bronchoscopic
oedema require the passage of the bronchoscope before re-
sorting to tracheotomy. The author uses tubes of 4 mm. and
5 mm. internal diameter for children under six. He is a strong
supporter of per-oral as against tracheotomic bronchoscopy.
In the palliative treatment of inoperable oesophageal cancerous
stenosis, he has found oesophageal intubation very satisfactory,
and by this means gastrostomy may be postponed ; intubation tubes
have been worn for quite a number of months without exciting ulcera-
tion, They were, of course, removed at frequent intervals for cleaning,
and were replaced. Jackson concludes his paper with the statement
that all future progress will depend on those who have the time and
the opportiinit}^ to develop an organization with assistants and nurses

Fig. 1 5.— Lewisohn’s rectangular tele-
scopic aesophagoscope. The small figure
shows the telescope closed.

NEW TREATMENT

BURSITIS, SUBDELTOID

171

well trained, and to develop by continual practice the skill such as the
musician must have with his instrument.

Sir St. Clan* Thomson^ records a case in which a’^toothplate, which had
been impacted in the oesophagus for two and a half years, was removed
through the mouth. The interest lies in the fact that the patient
had been examined several times by A'-rays and by oesophagoscopy,
and bougies were also passed with negative result, so that hysteria was
diagnosed. The plate was finally detected by Dr. Moore by the direct
method, and removed by the author.

Lewisohn^ has constructed an CBsophagoscope on a new principle,
which permits of the introduction of the instrument in the normal
position of the head. It passes in the longitudinal axis ol the oesophagus,
and not at an angle to it, and is passed under guidance of the eye. It
consists of two portions, which are jointed at almost a right angle :
a horizontal portion which lies in the mouth of the patient during an
examination, and a vertical portion consisting of a telescope of six
separate tubes which may be pushed down into the oesophagus as far
as necessary (Fig. 15). The lamp and condenser lie outside the
mouth at the proximal end of the horizontal tube. The total length
from the teeth to the end of the instrument is 45 cm. In examinations,
the pharynx is cocainized, and the patient sits on a chair, the head
being supported by an assistant. The first stage, or the anchoring of
the instrument in the oesophagus, is performed blindly. It is pushed
in the middle line to the posterior wall of the pharynx. The handle is
then raised until the ocular becomes horizontal, and in this way the
instrument glides automatically over the' epiglottis and arytenoids.
The second stage is done under the guidance of the eye, the telescope
being opened by pushing down a spring. When the examination is
finished, the spring is gently pulled until the telescope is again closed.

References. — ^Lancet. 1913, i, 16; -Ami, Surg. 1913, i, 28.

BUBO, CLIMATIC. Leonard Rogers, M.D., F.R.C.P.

A. J. J. Triado^ reports on fifty cases of this disease seen by him in
Western Australia. All occurred in white men who had had sexual
intercourse wdth aboriginal -women. The buboes are very chronic and
continue for months. If simply incised, the discharge continues
without any sign of healing. The only efficient treatment is complete
Excision, when the glands will be found to be separate and to show'
a little softening in their centres. The diagnosis from syphilitic and
gonorrhoeal buboes is quite easy.

Reference. — ^Austral. Med. Gaz. 1913, 442.

BURSITIS, SUBDELTOID. Pyiesiley Leech, M.D., F.R.C.S.

Flint^ recommends Aspiration of the subdeltoid bursa in acute
traumatic bursitis. He reports two cases w*here aspiration of 4 c.c. of
a clear fluid permanently relieved the condition. The symptoms were :
a painful point in front of and below the tip of the acromion process ;
palpation of the head of the humerus in the axilla is painless ; adduction

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172

MEDICAL ANNUAL

and also complete internal and external rotation with hand and arm
at the side are possible; abduction is limited to 15° or 20®, and there is
inability to put the arm behind the back. The effect of the aspiration
was instantaneous.

H. Flint thinks the chief factor carrying the condition on to chron-
icity, with marked thickening of the wall of the bursa, is not so much
the severity of the primary injury, as the repeated traumatisms caused
by movements of the shoulder-joint which cause the already distended
bursa to strike against the coraco-acromial ligament.

The method is as follows :
A Luer syringe is partly
filled with about i c.c. of
sterile cocaine or novocain
solution ; the solution is
injected into the skin, and
ahead of the needle as it
passes through the deltoid.
The needle is pointed
roughly parallel to the
clavicle and directed to-
wards the bursa lying just
over the bicipital groove.
The point of entrance is
about 2 cm. below the
level of the acromion
process. As the point of maximum tenderness lies directly over the
bursa, this will perhaps prove the best guide for the needle, for it was
at this point that fluid was obtained in Flint's cases {Fig. 16).

KEi'ERENCE. — ^JouY. Amer. Med. Assoc. 1913, i, 1224.

CAISSON DISEASE. Puwes Stewart, M.D., F.R.C.P.

Modern engineering often necessitates the use of caissons of com-
pressed air, within which the men have to work for periods usually of
three to four hours at a stretch. When entering the caisson, the
worker has little or no discomfort, and is in no danger. It is during
and after the period of decompression, when returning from the com-
pressed-air chamber to the ordinary atmospheric pressure at the surface
of the ground, that symptoms are liable to occur.

Etiologv. — Erdman was for two and a half years a member of the
medical stafl[ of the huge East River Tunnel between New York and
Long Island, in which over 10,000 men were employed, and where
between three and four thousand cases of illness of minor and major
severity were reported. In a valuable paper^ he records his experience
of the acute symptoms of caisson disease. The causation of the sym-
ptoms is now universally admitted to be the occurrence of air-emboli
in the blood and tissues. During the period of work in compressed air,
the fluid and tissues become saturated with an excessive amount of
atmospheric air. Whilst the man remains in the compressed air, no

NEW TREATMENT

173

CAISSON DISEASE

pathological symptoms develop ; but during the period of decompres-
sion, if this be carried out too rapidly, the air diffuses out of the capil-
laries, and is set free as bubbles in the body-tissues and fluids, forming
air-emboli, air-thrombi, or even larger collections of air in various parts
of the body.

During compression certain interesting phenomena occur which are
mechanical in origin and may be regarded as physiological. The rise of
atmospheric pressure pushes the tympanic membrane inwards, and
unless the pressure in the middle-ear be equalized by admitting air
through the Eustachian tube by Valsalva's or some equivalent method,
acute pain may result, and even rupture of the membrane. The body
temperature rises slightly and sweating occurs. The denser air offers
increased resistance to expiration and to phonation. Whispering
becomes impossible, and whistling difficult or impossible. The voice
loses its natural quality and becomes intensely nasal. A sense of
exhilaration develops, with unusual ease of movement. The pulse,
blood-pressure, and respiration do not change, nor does the composition
of the urine or sweat become altered. Hearing is not affected. During
decoynpression the body becomes chilled, owing to the falling tempera-
ture in the air-lock. A crackling noise is often heard in the ears as the
air escapes through the Eustachian tubes.

Pathological SyMPT-)Ms. — These occur after decompression is com-
plete. Out of 3,692 cases among the East River Tunnel workmen,
50 per cent occurred within thirty minutes and 95 per cent within three
hours. Only i per cent were delayed over six hours.

Pain is by far the commonest symptom, developing in 88 per cent
of the cases. It may occur alone or with other phenomena. The most
frequent site is in the knees, forcing the patient into an attitude which
is popularly known as the '' bends." Pains in the elbows and shoulders
are less common. It is probably due to an effusion of air in the neigh-
bourhood of the affected joints, either in the fascial planes under the
periosteum or, as Hill suggests, in the yellow bone-marrow.

Vertigo occurred in 5 per cent of cases, and is explainable by the
formation of bubbles in the labyrinth of the inner ear ; or, when accom-
panied by nausea and vomiting, it may be due to air-embolism of the
cerebellum. Cerebrospinal symptoms, paraplegia or hemiplegia,
transient or permanent, occurred in a little over 2 per cent. Dyspnoea
of an asthmatic type occurred in 1*5 per cent, possibly due to multiple
air-emboli in the pulmonary vessels. Prostration of moderate degree
accompanied the pain in 1-25 per cent, whilst collapse with partial or
complete unconsciousness happened in 0*5 per cent. Fatal cases were
twenty in number, or 0-54 per cent, occurring either with symptoms of
unconsciousness and collapse, or with pain, prostration, nausea, and
vomiting, or from paralysis either immediately or with subsequent
complications.

The late manifestations of caisson disease, i.e., the ailments met with
in compressed-air workers, years after the exposure and the acute
manifestations, have been studied by Bassoe,® of Chicago. He

CAISSON DISEASE " MEDICAL ANNUAL

exainined i6i such men, and groups them into three classes — caisson
myelitis, arthritis, and aural disease. Some men presented symptoms
belonging to two or all three of these classes ; but usually one set of
symptoms predominated. Out of i6i men, 87 had various affections
of the ears, causing permanent impairment of hearing in 65 cases ; 141
gave a history of ‘'bends,'' i.e., severe muscular and articular pains ;
34 had paralysis, generally transient and affecting the legs, although
3 men had permanent paresis of one and 3 of both legs ; 12 had signs
of disease affecting the spinal cord ; ii had incontinence or retention
of urine ; ii had chronic joint-pains and stiffness ; 33 complained of
vertigo, of whom 6 had nystagmus superadded, probably labyrinthine
in origin. Cases with permanent joint affections showed the clinical and
A' -ray phenomena of arthritis deformans. Some of them are probably
due to localized liberation of air in the neighbourhood of the articular
surface ; others are of neuropathic origin, secondary to spinal-cord
lesions. In every case where permanent deafness was present, this
was found to be of labyrinthine origin. Rupture of the membrana
tympani was rare, and in no case caused permanent deafness.

Treatment. — Caisson disease can usuall}" be prevented by taking
care that the worker is not decompressed too rapidly, and that he
passes through an air-lock in which the atmospheric pressure is
gradually reduced to normal, allowing about twenty minutes for each
atmosphere of pressure. This affords time for the air in the blood
to diffuse slowly into the lungs, instead of effervescing into the tissues.

For the actual treatment of caisson disease, the most beneficial
method is to place the man back in the air-lock without delay and there
to recompress the atmosphere to the original pressure at which he had
been working. In this way the effervesced air may be re-absorbed
into the blood. He is then slowdy decompressed again. In cases
where re-compression has not been carried out sufficiently early, i.e.,
within an hour or so of the .symptoms, we must be content with analgesic
drugs, massage, etc., and with the usual remedies for chronic spinal
cord affections.

References. — ^Amer. Jotty. Med. Sci. 1912, i, 520; -Ibid. 526.

CALCINOSIS, MULTIPLE SUBCUTANEOUS.

E, Graham Little, M.D,, F.R,C,P.

This seems to be a sufficiently definite disease, though extremely
rare, to merit separation and naming ; and Parkes Weber^ under the
above title describes a case occurring in a German girl aged 7 years,
showing a number of hard nodules in the subcutaneous tissue of the
extremities and trunk. The nodules were mostly smaller than a pea,
but some were much larger. They could be seen in skiagrams, being
especially numerous about the knee and hip ; they consisted largely
of calcareous material (calcium carbonate and phosphate) embedded
in a spongy network of connective- tissue. Occasionally the nodules
became inflamed, and discharged thin purulent matter mixed with
calcareous debris. , . ■ ,

NEW TREATMENT

175

CANCER

No cause could be ascertained, and there was no sclerodermia such
as has been associated with this condition in other cases ; such as that
reported by Hunter,^ in which calcareous deposits were found in
association \vith both sclerodermia and Raynaud’s disease. The
nodules had been present for about eighteen years when the sclero-
dermia had also shown itself ; the latter condition had invaded the
whole of the face, neck, buttocks, hands, arms, and knees. There
was marked sclerodactyly. The bones of the fingers were unaltered.
There was an increase of pigment in the skin all over the body.

The treatment consisted in inunction with Oil and subcutaneous
injection of Fibrolysin, continued for two months, and was productive
of marked benefit.

References. — Joitr. Child, Dis. 1913. 97; “Glasg, Med. Jour. 1913,
i, 241.

CANCER. {See also Arsenical Cancer, Breast, Lips, (Esophagus,
P-^NCREAS, Prostate, Rectum, Skin, Stomach, Tongue, Uterus.)

K. JV.. Monsarrat, F.R.C.S.
Diagnosis. — Certain methods for the diagnosis of cancer have been
published of late, of which the three following may be noted. •

{a). The carcinodia skin reaction, — ^In 1910 Elsberg, Neuhof, and Geist
proposed a method of diagnosis by skin reaction, the technique being
the subcutaneous injection into the forearm of 5 min. of a 20 per cent
suspension in salt solution of washed human red corpuscles obtained
from a healthy individual. Their results showed a characteristic
reaction in 89*9 per cent of cancer cases, and no reaction in 94*3 per
cent of non-malignant cases. Lisser and Bloomfield^ have done further
work on this reaction, in particular with a view of avoiding the
possibility of error from the presence of normal isohsemolysins. They
state that the reliability of the blood of the individual used must be
tested, the type which is reliable being that whose corpuscles are
neither agglutinated nor hsemolysed by any sera in vitro. About 15 c.c.
were withdrawn from this healthy source, and a 20 per cent suspension
injected subcutaneous^. A positive reaction begins to appear three
to five hours after injection, and when developed presents as a some-
what irregularly oval area raised from the surroundings, slightly bogg}^
on palpation, and often tender, varying in colour from a brownish-red
to a maroon. In 62 cases of verified malignant disease, two-thirds
gave a positive reaction and one-third were negative. In 94 control
cases, 91*6 per cent were negative and 8*4 per cent positive. A positive
reaction is therefore strong presumptive evidence of cancer.

(6). Ransohoff*- published a report two years ago showing that there
is a decided difference in the anaphylactic reaction when guinea-pigs
sensitized with blood-serum from a normal individual, and other
guinea-pigs sensitized with blood serum from a cancer-bearing
individual, are both given a final dose of blood serum from a cancer
patient. From these experiments he inferred that there is some
specific substance in the blood-serum of cancer patients, probably
absorbed from the tumour itself. He has applied this* method of

CANCER

176

MEDICAL ANNUAL

showing the difference in the anaphylactic reaction of normal and
cancerous blood-serum to the diagnosis of cancer. He reports his
results in 50 cases, 30 cancer cases and 20 controls. In all the cases
together the margin of error was 8 per cent ; the correct diagnosis
was made in 92 per cent ; in the cancer cases alone a correct diagnosis
was made in 86-7 per cent. The tests were never positive in
non-malignant cases. This work goes to show that the anaphylactic
test may prove of use in the diagnosis of early cancer ; there were five
early cases which gave positive results. The uniformity of negative
tests in non-malignant cases is a point of value, and a positive result
appeared to be reliable evidence of the presence of cancer.

(c). Sturrock® has carried out further work on the estimation of the
alkalinity of the blood-serum of cancer patients. He used and some-
what modified the “ dimethyl ” method employed by Moore and
Wilson. His results showed that the average alkalinity in cancer
cases was appreciably higher than in the non-malignant. They enable
him to state that a high alkalinity affords some presumption of the
presence of cancer — sufficient, he considers, to justify an exploratory
operation in doubtful cases. Low figures are not, however, any
guarantee of the absence of cancer. The method does not appear,
therefore, to be of much assistance in diagnosis.

Pathology. — ^W. J. Mayo** has drawn attention to the importance
of 1 ecognizing that carcinoma may be disseminated by grafting in the
course of operations. Spontaneous ontogenous grafting is a recognized
method of extension of the disease. Examples are found in the graft-
ing of cancer from lip to lip and from one part of the alimentary canal
to another. He gives some interesting illustrations. In one case the
disease attacked the needle punctures made in closing the abdominal
incision after a resection of carcinoma of the stomach. In another,
a case of cancer of the rectum, the disease was engrafted on the granu-
lating surface of a colostomy wound. During operative manipulations,
pieces of the carcinoma must have been loosened and left in the
sigmoidal pouch, and the granulating surface thus infected. He also
remarks that several cases of cancer of the. breast had come under
observation which had been squeezed and manipulated by ignorant
persons, until a comparatively curable case had been rendered hopeless
because of acute involvement of the skin and fascia. In amputation
of carcinoma of the cervix uteri, he considers that the cautery is
preferable to the knife, owing to the opportunity furnished by the
latter foi carcinomatous infection of the wound, and traumatic
dissemination through the lymphatic and vascular systems. On the
evidence, it is necessary to use technique which will exclude the
possibility of operative dissemination, and carcinoma should be treated
as though it were a focus of virulent infection.

E. T* ,P^ul® sho'ws that the histological features presented by
squamous-celled cancer give data for prognosis in given cases. Warty
growths are more favourable than ulcerating ones ,* the more malignant
a growth is, the earlier it breaks down and ulcerates. Cancer that

PLATE

VIII,

TYPES OF EPITHELIOMA

Fi^ym Illnsh'ftthns khuily ient by Dr. F. T. Paul.

Fix. good beginning for epithelioma (obj. i inch)

F/£. B.~~A bad beginning for epithelioma (o])j. i inch).

medical annual, Ii)i4

PLATE IX.

TYPES OF EPITHEL!OM (K—CMitinued

MLDIC.-IL .-IXXU.]!., 1)14

PLATE X.

TYPES OF EPITHELIOM k^coniinucd

E. A very malignant epithelioma of the ulcerating and infiltrating type
(obj. 5^ inch).

A'.— A bad lymphatic infection amongst the muscle fibres of the tongue
K inch).

MEDICAL AKKUAL,

NBW TREATMENT

177

CANCER

originates in scars, embryonic rests, and sebaceous cysts is usually
under the average in malignancy. On the other hand, when com-
mencing as the result of chronic irritation, it is usually very malignant.
With regard to early growths, the chronic warty tumour {Plate VIII,
Fig. A) is of good prognosis ; a widespread dowm-growth of fine
trabeculae of epithelium over an ill-defined area is the worst type
(Fig, B), and is characteristically seen in cancer of the tongue super-
vening on syphilis. The cell type is important. One of the most
favourable is that in which there are large processes of small uniform
cells, with slight tendency to cell-nest formation (Plate IX, Fig. C).
Such growths afford good prospect of cure by operation. When the
epithelial processes consist of cells with clear cell-bodies and small nuclei
(Fig. D), and the intervening connective tissue is small in amount and
shows little or no leucocytosis, the prognosis is also good. On the
other hand, when the cell groups are irregular, the nuclei and the cell
bodies variable in size, and nest-cells common, the prospect is bad.
Marked round-cell infiltration is also a bad sign (Plate X, Fig, E),
as is indifferent limitation. When cancer cells are present in lymphatic
vessels and spaces outside the area of the growth proper, the case
belongs to the worst type (Plate X, Fig. F.). There is then little
chance of permanent cure. A comparison of the naked-eye and
histological characters of growths is not only of assistance in prognosis,
but enables the surgeon to plan an adequate attack on the disease.

Howard W. Nowell® reports the results of experiments with a
crystalline substance extracted from fresh cancer material. Its
chemical composition has not yet been determined ; it was obtained
by an elaborate method of digestion, precipitation of soluble proteins,
extraction with alcohol and ether, and evaporation of a final aqueous
solution. The product thus obtained proved highly toxic to rabbits
and guinea-pigs. In addition to this general toxic effect, injection in
sublethal doses into rabbits produced “ well-defined, well-characterized
carcinomata,” the site of the primary lesion being different from, and
independent of, that of the injection. In an initial series of experiments,
three rabbits developed the clinical picture of malignant disease, the
degree of the development of the specific manifestation varying with
the site of the inoculation. The post-mortem examination showed
extensive and characteristic glandular involvement. In another
series, five rabbits received intra-abdominal injections. Although the
abdomen was the site of all injections, the primary lesions developed
severally as follows : one in the thyroid ; one on the right cheek
involving the nose and orbit ; one on the left foot ; the remaining two
on the head. All showed the characteristic progress of a general
cachexia. The necropsies demonstrated the presence of “ numerous
metastatic growths ; the histological examination leaves no doubt as
to the malignant character of both primary and secondary lesions.”
In another series an extract was prepared in a similar way from benign
tumours; but neither local nor general signs of toxic action were
produced. NoweE publishes no illustrations with his article. In view

CANCER

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MEDICAL ANNUAL

of the importance of the claims made for this research, there is a
regrettable want of precision in the report on the main contention, the
production of actual carcinomata by experimental injection.

There was an interesting discussion on the pathology of cancer at the
International Congress of Medicine. Bashford spoke on the subject
from the point of view of its experimental study. 'Generally he looked
upon cancer as an indirect result of chronic irritation, but no pronounce-
ment could be made as to the direct or actual cause. He did not
incline to the view that any cancer parasite ” was responsible, as in
addition to the fact that the disease differed in many respects from the
known infective diseases, it was difficult to conceive of a parasite
capable of determining at one time cancerous proliferation in epithelial
and gland cells, and at another in connective tissues. The only common
property of malignant tumours was the cell itself, and he was inclined
to believe that the cause which led to the proliferation and unbounded
growth was some subtle chemical or biological agent. He demonstrated
the results of experiments in the production of immunity to tumour-
grafting in mice and rats. He showed that a grafted tumour which
failed to grow' progressively conferred more or less complete immunit}^
to implantation ; a still more complete resistance was conferred by
embryonic skin, blood, and other tissues from the same species. He,
liowever, Avarned his audience that results obtained from immunizing
experiments were not to be regarded as indications of cures or even
protective measures to be applied to human beings.

At the same discussion, Freund stated that the normal blood con-
tained a substance w-hich "was able to destroy cancer cells. This
substance he had isolated, and demonstrated that it was a fatty acid.
It was not present in the blood in carcinoma, but in its place a substance
had been isolated which possessed the power of destroying the fatty
acid normally present. He considered that the destructive bodies
were present in the blood of every cancer case, and also in the organs.
He was of opinion that chronic physical or toxic irritation produced a
predisposition to cancer by destroying the normal fatt}' acids.

Lazarus-Barlow held that the etiology of cancer was inseparably
associated with the radio-active content of the tissues. Fadio-active
material w'as present in larger quantities in cancerous tumours than
in normal cells. He showed tables demonstrating that normal tissue
contained a quantity of radio-active matter represented by i, non-
cancerous tissues from individuals suffering from cancer contained
25, the primary tumour 51, and the metastases 55.

Treatment. — Zeller" publishes results obtained by the treatment of
cancer, mostly superficial, with Silicic Acid and a Mercury-Arsenic
Paste. These methods are not new', and w'hile they have their dis-
advantages (the paste causes much pain), they may be of service
under the conditions in which Zeller employed them. He gives
details of 57 cases, 44 of whom were apparently cured, wdth healthy-
looking scars. In the greater number the disease was on the surface,
but single examples affecting ear, upper jaw, lips, mamma, and vagina

NEW TREATMENT

179

CANCeR

were of the type of deeply infiltrating cancers, and healed after great
destruction of tissue. In 20 of the cases the diagnosis was verified
microscopically, in the remainder it was clinical only. The paste
used was the old cinnabar-arsenic paste of Astley Cooper. It was
applied thickly over the ulcers, and repeated in eight to fourteen
days according to the activit\^ of the reaction. The silicic acid was
given in the form of a powder, composed of equal parts of potassium
and sodium silicate, ^ gram three times daily. In a prefatory note
to Zeller’s article, Czerny credits the paste for the most part with the
results achieved, and commends its use in superficial inoperable cancers.

Abbe® gives an interesting summary of the present position of
Radium treatment, and also his own experience. The latter extends
to 750 cases, including 250 epitheliomata of all parts ; 180 carcinomata
of the tongue, throat, oesophagus, rectum, uterus, breast, etc ; 50
sarcomata of the skin, parotid, bones, etc. ; besides goitres, tumours
of the liver and mediastinum, and a variety of n^vi, moles, papillomata,
etc. Of the “ numerous failures,” he considered most were due to
inadequate amount or insufficient time of application, or error in
using the proper rays. The gamma rays are alone to be employed.
He endorses the opinion of Wickham, that malignant tumours must
first be excised as thoroughly as possible, and radium then used upon
the bed of the disease. The paper contains many valuable clinical
illustrations. The writer’s conclusions are : (i) An undoubted retro-
grade degeneration of malignant cells occurs under correct dosage of
gamma radiation ; (2) Effective use of radium lies in the application
of a large enough quantity to avoid the stimulating action of little
doses at short range ; {3) The utilization of gamma radiation with its
deep penetration can be made by the removal of alpha and short beta
rays by filtration through lead ; (4) Such filtration requires many

times as long for a sufficient amount of gamma rays to act, as when
other rays are eliminated by what may be called ” distance filtration.”
One and a half inches, or 4 cm., seems in practice to exclude most of
these, and gives free and instant play of the entire gamma range without
delay of passage through lead ; (5) Cross-firing of several specimens

simultaneous^, or of one large specimen moved successively to several
neighbouring places, is necessary for the best work ; (6) Normal tissue
resists many times as large doses of gamma rays as are required to
check and dissipate morbid growths.

Knox^ points out that while the action of radium cannot propeiiy
be called selecti\^e, it acts on cells according to their resistance, and
3^oung, actively-gr owing cells are more readily influenced than mature
cells. The cells of a new growth belong to this type. According to
this writer, in every early case of malignant disease, operative measures
should come first, but there are conditions under which radium should
be the second choice. The patient may refuse operation, and thorough
treatment by radium in early cases may lead to a disappearance of
the growth. The risk of operation may be too great. Inoperable
cases are many of them hopeless from the curative point of view, but

CANCER

MEDICAL ANNUAL

iSo

1‘adium will relieve pain, diminish discharges, check hsemorrhages, and
frequently heal up ulcers of considerable size* {See also Radium,
AND Thorium.)

Colloidal Copper has been credited with an influence on the growth
of cancer. Gelarie^o records some results of experiments in which he
injected cuprammonium sulphate and colloidal copper into mice
suffering from inoculated cancer. The results were rather indefinite ;
they showed that by means of these injections a certain proportion of
implanted tumours are changed into a stationary condition or undergo
retrogression. Complete disappearance, however, occurred in only
25 per cent of the mice treated with cuprammonium sulphate, and only
6*3 per cent of those treated with colloidal copper. WeiT^ gives the
results obtained in Cornell Medical College from a study of the effect
of colloidal copper on malignant disease in human beings. Twelve
cases were submitted to intravenous injection ; four received a thorough
and prolonged course of treatment ; four received between fifteen and
twenty injections ; in the remaining four the injections were dis-
continued in consequence of undesirable effects. Weil considers that
a demonstrable reduction in size of a tumour is the only really reliable
clinical guide to the efiect of treatment. In many, cases certain
improvement was witnessed as regards appetite, spirits, function, and
also in the character of the discharge. The treatment resulted in most
of the cases in the production of mild constitutional effects, such as
chills, nausea, some loss of weight, slight reduction of hsemoglobin,
and occasional albuminuria or haemoglobinuria. Chemical analysis of
two tumours from patients treated, failed to reveal the presence of
copper, while in a liver obtained at necropsy it was present in appreci-
able quantity. Judged by the standard of growth retrogression, the
treatment did not appear to exert a destructive action on the tumour
tissue in any of the cases. This careful report, though negative, is of
value in view of the claims put forward for this method of treatment.

References. — ^ Johns Hop. Hasp, Bull. 1912, 356; Jour. Anter-
Med. Assoc. 1913, ii, 8; Med. Jour. 1913, ii, 780; ^Joitr. Amer. Med.

Assoc: 1913, 512 ; ^Liverp. Med.'-Chir. Jour. 1913, i, 158 ; ^Bost. Med
and Surg. Jour. 1913, p. 83S ; "MUnch. med. Woch. 1912, 1S41 ; ^Lancet
1913, ii, 524; ^Brit. Med. Jour. 1913, i, 1196; "^^Ibid. 1913, ii, 222 : '^^Jour.
Amer. Med. Assoc. 1913, ii, 1034.

CANCER, LABORATORY DIAGNOSIS OP. (See also Blood, Examina-
tion OF.) Oskar C. Gruner, M.D.

The three sources of material for investigating the presence or not
of cancer in a person are: (i) The gastric contents', (2) The urine', and
(3) The stools. Much work has been done on these secretions during
the year.

Gastric Juice. — The glycyl-tryptophan test is discussed by A. Graham
Bryce^ and Friedmann.- The latter points out its fallacies : (i) Occult
blood gives a positive reaction, and fibrin occasionally does the same.
(2) Bile and pancreatic juice that have entered the stomach will give
the reaction, and it is necessary to make a preliminary test (bromine

NEW TREATMENT

CANCER

i8l

water is added to the filtered gastric contents) before adding the re-
agent, (3) If the acidity is more than 0*36 per cent hydrochloric acid,
the ferment responsible for the test in question would be destroyed.
(It is, however, extremely rare to have acidity at all in gastric cancer.)
(4) Strong tea would disturb the reaction. The facts appear to be that
in a number of cases, the test comes out positive in gastric cancers, but
it is not invariable to find a negative result in cancer cases. The work
of Bryce shows that while the reaction is never obtained in healthy
persons, or in chronic ulcers of the stomach and general diseases, it is
variable, not only in cancer of the stomach, but also in anacid and
subacid conditions, in hyperacidity, hypersecretion, and other diseases
of the digestive tract and its associated organs.

Schryver and Singer^ give a new method of examining the gastric
juice for cancer. They estimate the nitrogen in the gastric contents
in terms of the number of c.c. of decinormal soda solution required to
neutralize the ammonia produced by Kjeldahlizing 10 c.c. of juice,
and they make a dimethyl and phenolphthalein titration. Then if C
represent the phenol titration, B dimethyl, and A nitrogen equivalent,

^ g

— — is a constant. This figure, multiplied by 10, is called the nitrogen
A,

factor, and is found to be uniform in normal persons. The nitrogen
estimation and the determination of the nitrogen factor, give an index
to the amount and character (degree of digestion) of the products of
digestion.

Singer^ discusses the relation between sodium chloride and acid
chlorides in gastric juice. He endeavoured to ascertain the amount
of sodium chloride present in pure gastric juice in the absence of a test
meal. Cats were used, and it was found that the organic chloride is
largely conditional upon secretory or osmotic processes in the stomach
wall. The conclusion is that variations in this amount must be
reflections of pathological changes in the stomach.

Urine. — ^The substances to look for in cases of cancer are grouped
together by Davis, ^ who discusses the subject of hcBmo-itrochrome,
This substance is found in urine in a large number of cancer cases, and
is tested for by adding 10 c.c. of hydrochloric acid to 10 c.c. of urine,
boiling, cooling, and adding 30 c.c. of ether. The mixture is occasion-
ally agitated, and the ether poured off in two hours into a white dish.
\^Tien the ether has evaporated, the colouring matter is left on the dish.
On addition of a small quantity of i per cent sodium bicarbonate, the
colouring matter goes into a solution, to which methyl violet (-05 per
cent) can be added. The blue tint should turn red. [It is evident
from reading this paper that the new substance so-called is nothing
more than a bile-pigment derivative, although it is stated that the
amount present bears a distinct relation to the extent of the disease
in cases of cancer. — O. C. G.l

Colloidal nitrogen is in excess of the normal (3*42 per cent) in cancer
cases. According to Salkowski and many others, if the value rises
to 6 or 7 per cent, it is considered to be indicative of cancer.

CANCER

182

MEDICAL ANNUAL

Method : — Remove albumin by boiling. Slightly acidify, filter, and
estimate the total nitrogen by Kjeldahrs method. Evaporate 100 c.c.
of the same urine to 10 c.c., cool, and add 10 c.c. absolute alcohol. In
several hours filter and wash with alcohol, dissolve the precipitate in
hot water, and Kjeldahlize again. The difference gives the colloidal
nitrogen.

Sulphur-containing oxyproteids are increased in the urine in more
than 70 per cent of cancer cases, according to Salomon and Saxl (Davis.
ihid-).

The salicylate test of Salomon and Falk consists in washing out the
stomach, and then giving 3 grams of sodium salicylate as an enema. As
soon as the drug appears in the urine, wash out the stomach again.
If the drug is in the gastric contents also, the case is most likely to be
one of cancer.

Fjeces. — Bardachzi® refers to the examination of stools for occult
blood. There may be no reaction in cases of extreme stenosis of the
pylorus, but this constitutes the only exception. Ninety to g6 per
cent of cases yield blood in the stools if carefully searched for. In
Vay’s method the excretions are rubbed into a paste and allowed to
stand. Then take half a porcelain dishful and add one-third volume
glacial acetic acid. Boil three minutes, cool, add 4 c.c. of ether, shake
several times, centrifuge. Collect the extract on a dry filter. Then
mix the filtrate with 2 c.c. of 3 per cent peroxide of hydrogen freshly
prepared, and alcohol benzidin. The patient must not have taken
meat or soup for three days.

Blood Serum. — Complement Deviation and Complement Binding . —
Schenk’ says the v. Dungern method of sero-diagnosis of malignant
disease is not very reliable. A positive reaction must be interpreted
with caution, as even normal sera may contain bodies that will react,
while syphilis and tubercle may yield potent substances. But it is not
considered that the latest modification of all is of much value, and
indeed it may be assumed that the number of modifications that
appear in the journals each successive week are sufficient evidence
that this process is not worthy of the time expended upon it. It is
significant that the antigens successively employed are widely different.
Thus we have, in succession, advocacy of (i) aqueous extracts of
tumour, (2) ethereal extracts of tumour, (3) alcoholic extracts of
normal human blood, (4) acetone extracts of normal human blood.
Further, a positive reaction may be obscui'ed by the presence of too
much complement. More recently it has been advised to heat the
serum to 54® after adding soda, v. Dungern believing that this method
renders the risk of mistaking tubercle and s^^philis quite negligible.
Petridis® obtained good results in the diagnosis of cancer of the stomach
by a special modification of v. Dungern’s method.

References. — '^Med. Chron. 1913, July, 161 ; ^N.Y. Med. Jour. 1912, ii,
317 ; ^Quart. Jour, Med. 1913, July, 309 ; ^Lancet, 1913, i, 1663 ; ^Amer.
Jour. Med. Sci. 1913, 1,857; Wien. hlin. PFoc/z. 1913, 1531 ; Wien. hlin.
Woch. 1913. 1529 ; ^Berl. klin. WocJi. 1912, 2488 ; ^Milnch. med. Woch.
1912, No. 2.

NEW TREATMENT

183

CATARACT

CATARACT. A. Hugh Thompson, M.D,

Prognosis. — Statistics of Vision after Operation. — A comparatively
small number of cases carefully followed up will give more valuable
information than a larger number less carefully observed. Temple
Smith^ gives the final visual results of 50 cases operated on in private :
-J, 2 cases ; I-, 2 cases ; ii cases ; 18 cases ; 3 cases ; 6

cases ; 5 cases ; less than 3 cases (one required needling, the

other two had myopic fundus changes, but could see to get about,
though not to read). An iridectomy ^vas performed in all ; in a few
as a preliminary measure. In the last 23 cases, irrigation of the anterior
chamber was done with 0*7 per cent saline. These results, though not
brilliant, are probably a more reliable guide to the prognosis of an
average case than the more optimistic figures of some writers. No
case of suppuration occurred in this small series ; but that does not
mean necessarily that there was no sepsis, as there were 6 cases of
iritis.

Treatment. — Antiseptics. — Temple Smith, following the teaching
of Elliot, of Madras, and other Indian operators, \vashes out the con-
junctival sac just before the operation with 1-4000 perchloride of
mercur3^ lotion. In Madras, ElHot uses 1-3000. This generally
causes a mucous secretion, which is mopped away with sterile swabs,
and the sac is freely washed out with saline. Since this practice has been
adopted, the percentage of suppuration, w^hich was formex'ly 3*2 per
cent in Elliot’s clinic, has been reduced to nil. The disadvantage of
the method is that after the douching with the strong antiseptic, the e^^e
becomes red and angr^’^-looking, and one has to operate on it in this
condition. In India, where the condition of the lids is often very bad,
the procedure appears to be justified. The practice of European
operators may be compared with the above. Axenfeld,^ of Freiburg,
always makes a bacteriological examination of the conjuncti\’al sac
before operation. When he finds pneumococci, he treats the con-
junctiva for four or five da\’'S by douching three times a day w’ith
P3"0cyanase or perh^’drol (o'25 per cent). Further, on the night preced-
ing operation, the patient is given an injection of Kolle's or Romer’s
antipneumococcic serum. Elschnig, of Prague, also takes a smear
from the conjunctival sac before operation in all cases. If it shows
pneumococci or streptococci, hourl^^ douchings with 1-5000 ox^'cyanate
of mercury are employed, and the lacr^^mal sac is w^ashed out daily.
Most other operators on the Continent, as in England, consider it safe
to operate in the absence of conjunctivitis or duct trouble without a
special bacteriological investigation, and for douching use iveak ^saline.
Fuchs, for instance, only employs weak perchloride for special cases.

Intracapsular Extraction. — ^The controversy over Smith’s operation
continues, chiefly’- in the columns of the Indian Medical Gazette ; but
very little fresh light has been thrown upon it, and in England it is
only exceptionally performed. Nesfield® advocates a modification of
the operation, which consists in dividing the lower fibres of the suspen-
sory ligament prior to expression of the lens. It is these fibres wMch,

CATARACT

184

MEDICAL ANNUAL

if they are intact, prevent the lens coining out whole in its capsule
without the exercise of an amount of pressure which may be dangerous.
This division is effected by means of a silver wire hook passed into the
anterior chamber. It is four inches long, and as stout as a darning-
needle. The end introduced into the eye is bent at a right angle, the
bent portion being in. in length ; the angle must be flattened, and
the end polished quite smooth. This instrument is introduced as far
as the lower border of the lens. Its point is then turned downwards
and made to circuit the lower half of the lens margin. The advantages
claimed by Nesfield are, that it is far easier than the method of external
pressure for rupturing the suspensory ligament, that it reduces the
amount of pressure exercised on the vitreous to a minimum, and that
it permits the employment of a sclero-corneal incision, so that a small
peripheral iridectomy can be done instead of the usual central one
which destroys the circular pupil-

In criticism of this paper, Strother. Smith* (Allahabad) writes that
" Nesfield’s dislocator implies the passing of an instrument between
the iris and the lens, practically without touching either, as if the iris is
touched the* patient is very liable to wince and thus complicate the pro-
ceeding. If the lens is touched with the slightest weight, in many
cases the capsule will be lacerated. The wincing of the patient is also
very liable to cause the laceration of the capsule. When the instru-
ment has been got into position to sweep round the suspensory liga-
ment, have we any guide to indicate \vhere that position is ? We are
working in the dark. It may be on the lens ; it may be on the suspen-
sory ligament ; it may be up against the ciliary region, in which case
the patient will certainly wince and complicate matters.’' Strother
Smith considers it supremely complicated and difficult, much more so
than dislocating the lens by external manipulation.

References. — '^Austral. Med. Gaz. 1912, 648 ; ^Ophthalmoscope, 1912, 36;
^Ind. Med, Gaz. 1912, 382 ; Hhid. 1913, 145.

CATARACT, PATHOLOGY OF.

/. Burdon-Cooper, M.D., B.Sc., D.O. Oxon,

These researches originated in the discovery by the author of the
amino-acid tyrosin in the aqueous humour, following a discission for
high myopia, as far back as 1906. The aqueous humour from this case
was found crystallized after it had been preserved for a time in a sealed
tube, and tyrosin was detected among the crystals of phosphate and
chloride of sodium which constitute the major part of the crystalline
content of the aqueous. In seeking to account for the presence of this
body, which was decidedly unusual, it was found that the crystalline
lenses of the lower animals and the human lens, as well as the hair,
nails, and enamel of the teeth, structures w’hich are developmentally
related to the lens as having the same epiblastic derivation, all yielded
tyrosin on hydrolysis with a weak acid. It was therefore concluded
that the change which had been produced'^in the clear lens by needling
it, was one of hydrolysis of the lenticular proteid, with the production

PLATE XI.

tyrosin and chouesterin in cataractous lenses

Photographs by Dr. J. Burdou-Coopcr

MEDICAL ANNUAL, igil

PLATE XII .

TYROSIN AND CHOLESTERIN IN CATARACTOUS L E N SE S—

/^/iofo^ra/>'is h’ Pr. /. Lhinfoti-Coof>cr

ME n ICA L A X.Xl L , JQi^

NEW TREATMENT

185

CATARACT

of tyrosin. This, it is believed, is what actually takes place. The
opacity produced is finally got rid of by solution of its soluble consti-
tuents.

Having come to this conclusion, attempts were made to apply
it to the investigation of the changes in senile cataract. The aqueous
and lens were preserved and examined in every case of cataract operated
on, and as a result of this examination of several hundred cases, includ-
ing preliminary iridectomies, it has been satisfactorily shown that when
the lens was cataractous, tyrosin was present in it, and also in the
aqueous humour. The only logical conclusion which could be drawn
was, that the cataractous change in the lens was a hydrolysis. Simple
hydration will not account for such products as tyrosin and cholesterin ;
and the old theory of dehydration, which is still taught, is untenable
for many reasons which need not be given here. Cases of myopic
degeneration of the lens, which are well known now, seem absolutely
to veto this theory.

The examination of the lens and aqueous in cataract associated with
albuminuria and glycosuria has given very interesting results. In the
former, tyrosin is very greatly in evidence both in the lens and aqueous,
and the greatest quantity of t3nrosin found in the aqueous in any single
case occurred in an albuminuric {Plate XI y Figs. A, B, C, and D). No
evidence of cr3^stallized cholesterin was found in these cases. Without
going into reasons here, the writer concluded that this tyrosin was
derived solety from the lens, and was not the product of the decom-
position of albumins. Interesting in this connection is the part played
by the kidney in senile cataract. The specimens {Figs, A, B, C, and
D) show a great increase of tyrosin in the lens and aqueous, above
that which is found in cataract where there is no clinical evidence of
renal insufficienc3^ These findings have an important bearing on the
question of this relation of the kidney to senile cataract, and furnish
strong evidence that such a relation exists. The suppositions which
exist as to the character of this relationship at present are only specu-
lative ; but an enquir}?” into this would probably lead to valuable
results.

In cataract associated with glycosuria, in addition to tyrosin in both
aqueous and lens, there was a large quantity of cholesterin. The
specimen shown in Plate XI, Fig, E, shows both tyrosin and choles-
terin existing together in a cataractous lens. Cholesterin is met with
fairly frequently in the lens ; it is doubtful whether it has ever been
demonstrated as associated with tyrosin before. If it is correct to
look upon tyrosin as an indicator of a process, the nature of which is
believed to be simple hydrolysis, then cholesterin is indicative of some
change the nature of which still awaits solution, though it has been
known so long as a fairly frequent constituent of the cataractous lens.

In Plates XI, XII, Figs, F and G, tyrosin is seen existing in the
aqueous aiid also in the lens in a case of cataract with glycosuria in a
patient aged seventy. Plate XII, Fig, H, shows tyrosin produced from
the human lens by artificial hydrolysis with weak acid. Figs, I, K, L

CATARACT

i86

MEDICAL ANNUAL

show the method of demonstrating tyrosin in the aqueous by breath-
ing on the slide ; the sodium chloride, being hygroscopic, dissolves,
and shows up the relatively insoluble tyrosin. Fig, K shows a
slide not breathed upon ; while in Fig, L the stellate form of the
crystal shows up quite clearly.

It ought to be noted that the specimens have not been touched in
any way or by any chemical ; they are from lenses and aqueous direct
from the eye, and photographed within two hours in the majority of
cases. This hydrolysis theory of cataract accounts for the presence of
tyrosin in the aqueous after discission of the clear lens, and also in the
aqueous and lens in senile cataract. It accounts for the findings in
albuminuria and glycosuria. It is the only theory which accounts for
the pathology of black cataract and pigmentation of the lens generally.
It accounts for the diminished weight of the cataractous as against
the clear lens of the same age ; and for the diminished rate of growth
preceding the formation of cataract. It explains the more frequent
position of the opacity in the cortex, because it hydrolyses more readily
than the nucleus. Finally, it fits in with Prof. Dor’s observation that in
cataract the lento-albumin is very much less, and generally disappears,
because it is being hydrolyzed and carried away as tyrosin.

Fig, M shows t3^rosin in the lens in senile cataract,

CEREBROSPINAL PEYER, E, W. Goodall, M.D.

Symptoms, — A. H. Parmelee,^ of Kansas City, has published the
results of a careful study of 230 cases. The onset of the attack was
sudden in 83 per cent; the temperature reached 100° to i02’5®F. in 50,
and over 102*5° in 33*5 per cent ; the pulse was slow in 55 and rapid in
37 per cent. In 53*5 per cent there w^as delirium, and in 66 per cent
unconsciousness ; headache was present in 84 per cent ; in 96 per cent
rigidity of the neck was observed, and in 84 per cent set in early, while
in 3 per cent it was absent ; Kernig’s sign was present in 91 per cent.
Convulsions occurred in 21 per cent, vomiting in 76 per cent, herpes in
60 per cent, and petechias in 24 per cent. In 25*5 per cent of the cases
there was strabismus, and in 32 per cent the pupils were unequal ;
30 per cent of the patients were hyperaesthetic, and retention of urine
occurred in 17 per cent. In 53 per cent the number of leucocytes in the
blood was from 15,000 to 25,000 per c.mm., and in 31 per cent it was
over 25,000. In 6 per cent of the cases the spinal fluid withdrawn by
lumbar puncture was clear at the first, but cloudy at subsequent
punctures ; in only i*8 per cent could meningococci not be demon-
strated in the fluid at the first puncture, while in 2*3 per cent they were
not found at any puncture. Relapses took place in about 5*5 per cent ;
nearly 8 per cent of the patients were deaf, and in nearly 8 per cent
arthritis occurred ; in about 5 per cent hydrocephalus ensued.

A somewhat similar account of the disease has been furnished by
F. J. Slataper, of Houston, Texas, from an analysis of 210 cases. He
states that in 10 per cent there occurred, as an early symptom, a
subcuticular mottling, that quickly covered the entire body, and after

NEW TREATMENT

CEREBROSPINAL FEVER

187

a few hours disappeared as suddenly as it came out. In 8 per cent of
his cases the disease set in with the signs and symptoms of acute
pneumonia. Herpes labialis was present in 58 per cent, and a petechial
rash in 78 per cent. Relapses occurred in 17 per cent, arthritis in 14
per cent, and bronchopneumonia in 58 per cent. In 6 per cent the
disease became chronic. This writer mentions two forms of Kernig's
sign : when the patient cannot extend his own leg on the thigh, which
is held at right angles to the abdomen, it is said to be “ active ” ; it is
“ passive ” when some one else cannot extend the leg. Kernig’s sign
may be reinforced by holding the chin flexed toward the chest while
the test is being conducted in the usual manner.

Diagnosis. — H. Koplik^ points out the dif&culty in the diagnosis of
cerebrospinal fever in children under two years of age. “ Particularly
difficult are the cases in infants which are complicated with a pneumonia.
Many cases of pneumonia are complicated with cerebral symptoms ;
there is the restlessness, rigidity, retraction of the head, and the fever,
which continues a long time past the initial pliase of the disease. Again,
there are in young infants a number of cases in which the initial symp-
toms of fever and restlessness are not combined with other symptoms,
such as rigidity. . . . Many diseases of infancy, even a simple intestinal
disorder, are so often combined with milder forms of cerebral symptoms,
that we can easily explain how a meningitis in younger children and
infants is often overlooked. The physician is alive to the presence
of a Kernig,'' but this is certainly absent in many infants, and is of
little value in the diagnosis of meningitis. . . . The stress of diagnosis
must be placed on the persistence of cerebral symptoms, high fever,
and, what is of greatest import and scarcely appreciated at its full
value, Macewen’s percussion note over the fronto-parietal junction as a
sign of increasing fluid in the head.'’ This writer is of opinion that
in infants, lumbar puncture for the purpose of diagnosis should be
performed early, even on the suspicion of cerebrospinal fever, because
of the great danger there is in delaying, even for a day, the injection of
the specific serum. In older children a day’s delay is not dangerous,
“ Quite early, at the outset in many infants, the subarachnoid space
at the base of the brain is cut ofl from that of the cord, with the result
that lumbar puncture with introduction of serum becomes fruitless
quite early — on the second or third day of the disease in some infants.”

Treatment. — Koplik also insists upon the necessity for withdrawing
the cerebrospinal fluid and injecting the curative Serum very slowly
and cautiously in infants under two.

J. R. Charles^ records three very severe cases, in two of which re-
covery took place, after treatment by intraspinal injection of Flexner's
serum (15 to 30 c.c. daily) and Urotropin, 10 gr. every four hours.

The Intraspinal Injection of Serum has in a few instances been
attended with immediate, severe, and in some cases fatal results.
These have been attributed to four different causes, viz., the phenol
which has been added to the serum as a preservative, anaphylaxis,
rapid lysis of the meningococci by the serum, and excessive intracranial

CEREBROSPINAL FEVER l88 MEDICAL ANNUAL

pressure. These causes are discussed in detail by Simon Flexner.® He
shows that the phenol can be absolutely acquitted; that hardly any
case can be made out for the theory of lysis of the cocci ; that anaphy-
lactic shock is very rare ; but that in most of the instances the untoward
event can be put down to sudden increase in intracranial pressure.
Usually respiration has failed before the heart has ceased to beat, and
artificial respiration has frequently restored the patient. Lately the
practice has been to give considerably larger injections of serum than
was formerly the case, and the danger of increased pressure has been
forgotten, because of the infrequency of the occurrence with smaller
quantities. The serum should therefore be allowed to enter the spinal
canal by gravity rather than by the force of the syringe. By this
method it can be introduced slowly, and, moreover, the fluid can be
immediately withdrawn at the first sign of respiratory embarrassment.
Flexner speaks with approval of Sophian's method, described in the
last volume of the Annual, in which the registration of the blood-
pressure supplies an ocular guide to the injection of the serum by
gravity. His paper has appended to it a number of useful references.

Prophylaxis. — In the last volume of the Annual an account was
given of the vaccination of eleven adults against cerebrospinal fever by
Sophian and Mack. Eleven months after these vaccinations Mack®
tested the immunity of eight of these persons, and compared their
blood with that of a normal person, and also that of a patient who had
just recovered from a severe attack of cerebrospinal fever. He finds
that prophylactic vaccination produces a high degree of immunity in
most cases, this immunity being demonstrable at the end of one year.
It seems a justifiable conclusion that most individuals prophylactically
vaccinated may safely consider themselves immune for at least one
year. Exceptions to this will, of course, be found. Some individuals
may show an actual increase in immune bodies at the end of one year
over those demonstrable soon after vaccination. Fixation of comple-
ment occurred with the serum of the positive control who had recovered
from meningitis, but this fixation did not reach as high dilutions as did
that of some of those vaccinated. This has previously been found in
some others recovered from the disease. Mack thinks that experimental
evidence warrants the conclusion that prophylactic vaccination is a
measure of the greatest value in the control of epidemic meningitis.

References. — ^Jouy. Amer, Med. Assoc. 1913, i, 659; ^N.Y. Med. Jour.

L 347; ^Jour. Amer. Med. Assoc. 1913, i, 1753; ^BHst. Med.-Chir.
Jour. 1913, 142 ; ^Jour. Amer. Med. Assoc. 1913, i 1937 > Mbid. 1289.

CEREBROSPINAL FLUID. (See also Syphilis Cerebrospinal.)

Oskar C. Gruner, M.D.

The analysis of cerebrospinal fluid should take into . consideration
its quantity, clearness or turbidity, presence or absence of albumin
and globulin, capacity for reducing Fehling's solution, and cytology.
It is convenient to divide the different fluids into those that are clear
and those that are turbid. According to Blatteis and Lederer,^ clear
fluids are found in tuberculous meningitis, in cases of meningismus

NEW TREATMENT CEREBROSPINAL FLUID

(especially pneumonic), typiioid fever, in nephritis with unemic
symptoms, and in syphilis. Turbid fluids are found in cerebrospinal
fever, pneumococcic meningitis, poliomyelitis and polioencephalitis,
and in the meningitis secondary to ear disease. The characters of the
tuberculous fluids are— formation of a flocculus, positive Heller test
for albumin, negative reaction to Fehling’s, and Ijnnphocytosis.
Tubercle bacilli are present. Globulin is present in both tuberculous
and cerebrospinal meningitis. In the latter disease, of course, the
deposit contains pus. These authors found the commonest organism
of cerebrospinal fluid to be Streptococcus pyogenes.

Albumin Content— Sicoxd. and Foix^ place 2 c.c. of the fluid in a test
tube and add 6 to 7 drops of fuming nitric acid. An immediate preci-
pitate is interpreted as follows : Opalescence (first degree) occurs in
healthy fluid, and in Pott's disease that has been cured. The second
degree, consisting of fairly rapid opalescence increasing on standing,
no cellular exudate being present, occurs in cases of slight compression
of the cord. The third degree, immediate turbidity with very few
cells, means compression from without the cord (e.g., early Pott’s
disease). In the fourth degree — yellowish discoloration with a heavy
clot — a moderate number of cells means greater compression and even
pach5nneningitis. The more albumin and the more cells, the more
likely is the lesion to be in the pia mater.

Greenfield^ considers that a high albumin content indicates operative
treatment. In his study of the fluid he used Noguchi's butyric test.

The tests for albumin are as follow : (i) Nonne’s Phase i test ; mix
equal parts of the fluid and of ammonium sulphate (saturated while
hot and then cooled). Turbidity means that albumin is present.
(2) Nonne’s Phase 2 reaction, is as the preceding, but acetic acid is
added. Turbidity may now appear in normal states. (3) The Ross-
Jones test is a ring test with ammonium sulphate. (4) In Noguchi's
test, to 2 c.c. fluid are added 5 c.c. of 10 per cent butyric acid. Boil,
add I c.c. normal soda (7 per cent), and boil again ; a precipitate
indicates the presence of albumin. (5) Kaplan’s Test. Into succes-
sive tubes place ’5, *4, *3, ‘2, and *1 c.c. of fluid. Make all up to *5 c.c.
with distilled water. Boil each, and add 2 drops of 5 per cent butyric
acid. Boil again, and underfloat 5 c.c. of super-saturated ammonium
sulphate in each tube. Look for a thick cheesy ring in twenty minutes.
(6) The colloidal gold chloride test (Lange) is described by Grulee and
Moody. ^ The test solution consists of 500 c.c. of freshly doubly distilled
water, heated to 60° C., 5 c.c. of i per cent gold chloride, immediately
followed by 5 c.c. of 2 per cent potassium carbonate. The mixture
is brought to a boil, and 5 c.c. of i per cent formalin are added quickly.
Shake well. The solution should come out red with a tinge of yellow,
and be absolutely clear. Into a test tube place i*8 c.c. of 10 per cent
sodium chloride.' Into nine other tubes place i c.c. of 1*4 per cent
sodium chloride. To the first tube add *2 c.c. of cerebrospinal fluid,
mix well, take out i c.c. and place into the second tube, and repeat in
the same way for all the others. To each tube add 5 c.c. of the test

CEREBROSPINAL FLUID igo MEDICAL ANNUAL

solution, and allow the tubes to stand for twenty-four hours. A
precipitate constitutes a positive reaction. The precautions necessary
are absolute cleanliness of glassware, absolutely pure water, no rubber
connections, and s^reat care in lumbar puncture.

The Fehling Test. — Without considering the nature of the substance
that gives the reaction, its presence or absence remains of significance
in the diagnosis of certain conditions (Jacob®), Equal parts of the
fluid and the test solution are boiled in a narrow tube and allowed to
stand for an hour. A marked yellow deposit constitutes a positive
reaction. It is absent in pneumococcic, streptococcic, and mixed
infections, in acute stages of cerebrospinal fever ; present in tubercu-
lous meningitis and poliomyelitis. If found in cases of cerebrospinal
fever it means progress towards cure.

Cytology. — Roger® recommends Nageotte’s chamber. He mixes
the fluid with Unna’s blue or crystal violet. The centrifuge must
not be used. The maximum number of cells per c.c. in normal
fluid is 2. From 2 to 4 are found in syphilitic cases ; above 4 in
varying degrees of leucocytosis. (N.B. — ^The tendency which leuco-
cytes have to adhere to glass must be taken into consideration. —
Greenfield). Plasma cells indicate syphilitic meningitis, according to
Jeanselme and Chevallier. A preponderance of lymphocytes occurs
in an obsolete meningitis or parasyphilis ; large lymphocytes with
plasma cells and occasional pol3muclears in acute or incipient menin-
gitis ; abundance of polynuclears in acute meningitis.

Biological Tests. — Roger® refers to examination for trypanosomes
and for Wassermann reaction. A new test by Maruyama’ is used for
cases of general paralysis, and based on an anaphylactic process. It is
performed as follows: *02 c.c. human serum is injected subcutaneously
into a guinea-pig. In two or three weeks the cerebrospinal fluid
of the patient is injected intravenously, using 1*5 to 2 c.c. per 100
grams weight of animal. If the disease be present, the animal dies
with spasms within a few minutes. In the case of other psychoses
the animal does not die.

Drug Tests. — ^The detection of potassium iodide or nitrates in the
cerebrospinal fluid has been utilized for diagnosing acute inflammation.
They do not appear in chronic cases (Roger®).

Anthrax bacilli were found in a case of internal anthrax by Pollak>®

The signs of syphilitic infection in cerebrospinal fluid, are (i) Lympho^
cytosis, (2) Hyper-albuminosis, (3) Wassermann test positive in tne
blood, (4) The same in the fluid. If the third is present without the
other three, the case is certainly not one of S3q)hilis of the nervous
system. If all four are positive, the case is very severe. .The first
two with fourth indicate a severe degree of affection of the meninges.
A positive gold- chloride reaction (see above) is of use for diagnosing
congenital syphilis (Grulee and Moody^).

References. — ^Jouv. Amer. Med. Assoc. 1913, i, 81 1 ; ^Presse Med, 1912,
1013 ; Mancet, 1912, ii, 6S3 ; ^Jour. Amer. Med. Assoc. 1913, ii, 13 ; ^Brit.
Med. four. 1912, ii, 1097 ; ^Presse Mid. 1913, 305 ; "^Wien. him. Woch. 1913,
1233 ; ^Ihid. 1912, 1702.

NEW TREATMENT

CHOLERA

191

CEREBROSPINAL SYPHILIS. {See Syphilis, Cerebrospinal.)
CHLOROMA. [See Leukaemia.)

CHOLERA. Leonard Rogers, M,D,, F,R,C.P,

E. D. W. Greig ^ has been on special duty in Calcutta investi-
gating the epidemiology of cholera, and has obtained the following
important results. During a serious epidemic at the Jaganath Car
Festival at Puri, he made cultures from the gall-bladder in 271 fatal
cases, and isolated the vibrio in no less than 81, while in 12 naked-eye
changes were found in the wall. In one patient, who died of uraemia
on the thirteenth day, these were particularly well marked, while vibrios
were also found in the lung, so he suggests that late deaths may be
partly due to toxins of comma bacilli which have gained a footing in
the gall-bladder or tissues. Further, in no less than 36 per cent of
recovered patients, comma bacilli were found in their stools at the time
they were discharged from the hospital, to be widely scattered over
India by the railway. As upwards of 150,000 pilgrims were present
at the festival, it was not surprising that the disease was spread by
them over the Central Provinces and other areas. In 2 convalescents
he found cholera organisms in the stools thirty and forty-four days re-
spectively after the acute attack. Again, out of 27 healthy people who
had been in close contact with cholera patients, 6 were excreting cholera
vibrios in their stools, and were thus potential carriers of the infection.
The serum of convalescent cholera carriers was found to agglutinate the
organisms, while those who did not continue to excrete vibrios did not
show agglutinins in their blood. The Widal test may thus prove to be
a means of detecting cholera carriers more easily. An outbreak was
produced in the Puri gaol by the admission of a man recently con-
valescent from cholera, who was proved to be a " carrier.” Flies
caught in the vicinity of cholera patients were found to have vibrios
on their appendages and in their alimentary canals. He thinks water
could be excluded as a source of infection at Puri. As a preventive
measure the stools of all the inmates of the gaol were disinfected with
cyllin, and four days after, the outbreak ceased. The disinfection of
the fresh night-soil of the town was then carried out by means of a
solution of fresh chlorinated lime, which is cheap, a good bactericide,
and by its odour a check to flies. In spite of private privies escaping
the measure, the epidemic rapidly subsided ; it appears to have already
been on the wane when the disinfection was started, but this method
is worthy of further trial.

R. Kraus® and his colleagues report on their experiences of cholera
in the Bulgarian army during the recent war. Doctors and nurses
were deficient, and 1849 deaths occurred up to the end of November,
1912. It was partly explosive water-borne disease, and partly sporadic,
due to carriers and mild unrecognized cases, carriers forming 4 per
cent of those examined. Nine bacteriological stations were formed,
stretching from the fighting line to Sofia. Men were made to take an
oath to drink only boiled water. Special infectious hospitals were

CHOLERA

192

MEDICAL ANNUAL

erected, and suspicious cases separated from the wounded, sporadic
cases being thus eliminated. As it was impossible to find all the
carriers, contact infection could not be entirely prevented, and Kolle's
dead vaccine was largely used for inoculating the wounded. Rogers'
Hypertonic Saline treatment was tried. It had no visible effect in the
most acute cases which die in a few hours, but in some severe cases
rapid improvement was noted. Tinct. lodi in 3- to 5 -min. doses three
times a day had a beneficial effect in cases of diarrhoea, but was not
tried in cholera.

Treatment. — R. Emmerich^ gives an account of hypertonic saline
treatment, and states that absorption of nitrites causes the fall of blood -
pressure by paralyzing the blood-vessels, and also causes uraemia by
producing necrosis of the renal epithelium. He goes on to consider
the action of permanganates in destroying the nitrites in the bowel in
cholera, and gives evidence to show that free permanganous acid is
converted in the stomach and intestine into colloidal supermanganous
superoxyhydrate, and this colloidal MnOg neutralizes the fearfully
toxic action of the nitrites. Colloidal Permanganate is easily and
cheaply prenared by the action oi potassium permanganate on gelatin.
He considers that the striking specific action Rogers obtained in cholera
with permanganates must be due to the transformation of nitrites into
the harmless nitrates in the intestine, and the earlier it is used the
better. He does not, however, recommend it as prophylactic, for
which purpose he advises the administration of amidosulphonic acid
as a 10 per cent solution in small quantities, or better, free drinks of
a I ”1000 solution, which can be supplied in a pure state by Dr. Raschig,
of Munich. He thinks the permanganate treatment the most important
yet produced in cholera therapy. [The waiter has tried colloid
permanganate kindly sent him by Professor Emmerich, and found it to
have the great advantage of being practically tasteless ; he has used it
in a few cases in children with apparently good results. Unfortunately,
it is very unstable in solution, except when kept in sealed flasks. —
L. R.]

J. W. D. Megaw® records his results in the treatment of cholera in
Calcutta by Rogers* method during 1911. As he had also been in
charge of the cholera ward in 1905 and 1906, before the introduction
of the new methods, he was in an exceptionally favourable position to
compare the results during the two periods. In former times the
mortality at the Calcutta Hospital has been found to remain fairly
constant at about 60 per cent over a number of years, while during
the nine months under review 112 cases were treated, with 36 deaths,
or a mortality of 32*1 per cent. Among 94 more serious cases requiring
transfusion, the deaths numbered 34, or 37*2 per cent. The high
proportion of severe cases leaves little doubt about the diagnosis, but
bacteriological examinations were also made. A great improvement
in the care and nursing of the patients accounts for a small proportion
of the improved results. He advises early transfusion in all cases
of any severity, without waiting for the blood -pressure to fall and the

NEW TREATMENT

193

CHOLERA

blood to become concentrated and charged with toxins. Prompt
intravenous Hypertonic Saline injections maintain the circulation in
the vital organs and eliminate toxins. He suggests that washing, out
the stomach with permanganate solutions might be an improvement
on giving solutions to drink, while the permanganate pills are some-
times unsatisfactory. In some cases he found the alkalinity of the
blood greatly diminished, but in that stage he found intravenous
injection of alkalies was of little effect, though it might be of use earlier,
as suggested by American observers. He considers the method of
great value in saving life, and also in relieving much distress and
suffering.

G. Duncan Whyte® records a study of 215 cases of cholera treated
with hypertonic intravenous salines by Rogers' method at Swatow,
in China. As a rule permanganates -were not administered, as in a few
cases in which they w^ere tried they seemed to increase the vomiting
and discomfort of the patient. He emphasizes the simplicity of the
method. In taking the specific gravity of the blood, he uses only tw^o
bottles, of 1062 and 1066 respectively, and prefers a mixture of castor
or olive oil with oil of wintergreen, for the blood does not mix with
this as it does with glycerin and water. The result must be corrected
for temperature, and the oils made up every few days, as the oil of
wintergreen is the more volatile. If the drop of blood rises briskly
in the 1062 bottle, transfusion is not required. If it floats or sinks
slowdy, 80 02. of saline should he given, while if it also sinks in the
1066 one, 120 oz. should be given at onc' A blood-pressure of
70 mm. or less was also taken as an indication for transfusion, as advised
by the originator of the method. The simplicity of the treatment is
borne out by the fact that the first 500 cases wnre treated in their
houses, and in not a single case did thrombosis or embolism occur.

A boiled 2 per cent solution of / 3 -eucaine produced a satisfactory
local ansesthesia. The internal saphenous vein over the internal
malleolus was usually selected, or one of the veins on the back of the
hand. Out of a large number of cholera cases in which the blood-
pressure did not fall below 70 mm., every one recovered. Of 215 cases
with louver blood-pressure treated with intravenous infusion, 150, or 70
per cent, recovered. No case w^as refused treatment, and no deaths
occurred -which are not included in the above figures. The cause of
death was collapse in only 5 per cent. The more acute the onset, the
more likelihood of sudden collapse occurring, a few cases being too
virulent to be saved. Pituitrin and Adrenalin Chloride were also used,
and appeared to be of service. When there was difficulty in giving
nourishment owing to persistent vomiting, dextrose was dissolved
in the saline to sustain the strength. About half the deaths were due
to hyperpyrexia. By taking the rectal temperature, and if it was high,
giving the infusions below blood-heat, as advised by Rogers, very few
developed h3q)erpyrexia. Almost all the deaths in children, and most
in those over 40, were due to this cause ; in both classes of patients
they recommend that the inflow- of saline should be slow^er, and the

CHOLERA

194

MEDICAL ANNUAL

quantity regulated by the age, sex, and weight of the patient, as well
as the specific gravity. To free the saline from organic matter, it
should be passed through a Berkefeld or Pasteur filter before use.
To prevent l^perpyrexia, frequent observations of the rectal tempera-
ture must be made and prompt measures taken if it reaches 104° F.,
Iced Rectal Salines being the best, together with cold sponging. Uraemia
caused 7 per cent of deaths, mostly in patients over 50, only one
being under 40 years of age. Extract of Apocynum Cannabinum, in
2-min. doses every three or four hours, was found best for raising the
blood-j)ressure in this stage. For diluting the blood in threatening
uraemia, normal saline (60 gr. of sodium chloride to the pint) intra-
venously, and sterile water per rectum are good, the latter being given
twice daily. Dry Cupping over the kidneys was also used. He
disapproves of Sarkar’s (see below) suggestion, habitually to use vaso-
dilators ill uraemia, on account of the dangerously low blood-pressure
associated with the disease.

G. B. Sarkar’ agrees as to the great value of hypertonic salines in
treating the collapse stage of cholera. He discusses at length the
condition of post-choleraic uraemia, urging that the danger is increased
by vasoconstrictors, such as adrenalin, digitalis, and caffeine, and
advising the opposite line of treatment, i.e., the use of nitrites to
dilate the renal vessels, for which he claims good results. [This is
contrary to the writer’s experience, although he is inclined to think,
as a result of long trial, that Potassium Citrate is useful in checking
the diminished alkalinity of the blood. — L. R.]

References. — '^Lancet, 1912. ii, 1425 ; ^Ind. Med. Gaz. 1913, 8 ; ^Wien.
klin. Woch. 1913, 241 ; ^Munch. med. Woch. 1912, 2609 ; ^Lancet, 1912, ii,
1424 ; ^China Med. Jour. Mar. 1912 ; ’^Pvact. 1912, 697.

CHOREA. {See Rheumatism in Childhood.)

CONJUKCTIYA, DISEASES OF. A. Hugh Thompson, M.D.

Among the poorer classes, no disease is responsible for so much
damaged sight as phlyctenular conjunctivitis, because, in a considerable
proportion of cases, it spreads to the cornea and becomes a keratitis,
leaving corneal scars 'which in many cases become permanent nebulse
[Plates XIII, XIV, Figs. A and C). The disease is certainly dependent
in many cases on defective nutrition ; among the better-fed classes it
is rare. Even among poor immigrant Jews, whose children are, as a
rule, comparatively well fed, it is uncommon.

To what extent bacterial infection enters into the causation is a
matter of dispute. In 1906 Nias and Paton found so close a correspon-
dence between the rise and fall of the opsonic index for tubercle, and
the development and retrogression of phlyctenules in children, that
they argued that they must be of tuberculous origin. The most
common organism occurring in phlyctenules, however, is the staphylo-
coccus, and according to Macka^L^phtyctenules are a local manifestation
of staphylococcic infection in a soil well suited for tuberculous cultiva-
tion. Bishop Harman found that in early cases examined by himself

EASES

NEW TREATMENT IQ5 CONJUNCTIVA

the contents of unbroken phlyctenules were sterile. He points out
that the disease is most common from four to six years of age, when the
milk teeth are decaying, and he looks upon it as a '' herpetiform erup-
tion caused by peripheral irritation of collateral branches of the second
division of the fifth cranial nerve in ill-nourished children.”^ A theory
of more complex causation, in which tubercle, malnutrition, and ali-
mentary toxaemia each bear a part, is found in a paper by Walter, of
Chicago.® An interesting side-light on the share pla3^ed by malnutri-
tion is supplied by Professor Straub, of Amsterdam, who determined
the specific weight of normal and scrofulous children respectively by
submerging them up to the neck in tepid water, measuring the volume
of displaced water, and comparing this with the weight of the children.
He thus found that in the great majority of cases scrofulous children
have a specific weight very near that of water, whilst the specific
weight of normal children is higher.-* This difference may be ascribed
to the variation in the density of the bones due to the deposit of lime
salts in the bones of normal children, and the lack of such deposit in
scrofulous types.

The trea-fcment of phlyctenular disease, local and general, is well
known, and in the majority of cases the immediate results are gratify-
ing. Walter, in addition to ordinarj^ treatment by Yellow Ointment
and Cod-liyer Oil, recommends the Gastro-intestinal Treatment, which
has been practised for many years in America. It consists in the with-
drawal of all cane-sugar combinations, all acids, tea, and coffee, and the
sterilization of the intestinal tract by small doses of calomel continued
over many days. The difficulty in these cases is, not so much to cure
the particular attack as to prevent relapses. General hygiene is of
primary importance.

Tuberculosis of the conjunctiva is a comparatively rare condition.
When seen it is most often in the form of an extensive ulceration
of the palpebral conjunctiva [Plate XV). “ An ulcer of this des-
cription,” sa^’S Ormond,® ” hidden as it is in the loose folds of the
conjunctiva, may only draw attention to its existence by a slight full-
ness of the lid, with watering of the e\^es ; when the upper lid is involved,
ptosis is usually noticed. The pre-auricular gland is involved eaidy, so
that the patient, when looked at from the front, display's a puffy
swollen lid with a swelling in front of the tragus.” Other cases are
occasionally seen in which there is a pedunculated or sessile tumour of
the palpebral or ocular conjunctiva. A drawing of one such is repro-
duced (Plate XU I, Fig, B). In other instances it is associated with
lupus of the face. The treatment of these cases was formerly vigorous
scraping or incision, ” but this,*' says Ormond, ” invariably led to severe
cicatricial contraction and distortion of the lids.” The surface only
of the ulcer should be scraped, to remove the necrosed tissue, and for
the rest, the main reliance should be placed on Tuberculin, an injection
of *0002 mgram being given every ten to fourteen days, the dose onl}^’
to be increased if the temperature remains normal after the preceding
injection. This special treatment must be combined with the general

CONJUNCTIVA

196

MEDICAL ANNUAL

hygienic treatment of tuberculosis, and with local antisepsis, best
carried out by flushing the conjunctival sac three or four times a day
with iodine water.

Parinaud's Conjunctivitis, — An example of this rare disease, with
an illustrative drawing, will be found in the Medical Annual for 1909
{p, 217), The involvement of the pre-auricular gland gives it a great
resemblance to some cases of tubercle of the conjunctiva. According
to Mdllers, ® the two diseases are identical. From two cases diagnosed
as Parinaud's conjunctivitis,” he obtained tubercle bacilli which
proved, on cultivation, to be of the human, not bovine, type. Both
these cases were in patients infected with tubercle elsewhere in the
body, and the fact that cases of Parinaud's conjunctivitis generally
run a favourable course is accounted for by Hollers on the theory
that the primary infection has established a relative immunity* The
subject evidently requires further investigation, and as the conditions
treated of are decidedly rare, it may take some time before the true
connection between them is established.

Incidence of Ophthalmia Neonatorum. — ^The number of cases of this
disease notified to the London County Council in the first nine and a
half months during which compulsory notification was in force was
673, which, compared with the number of births for the same period,
gives an incidence of *843 per cent.’ This closely agrees with the result
of a private census by Harman in 1906, who found an incidence of *867
per cent.® It may therefore be said that in London the disease attacks
less than one per cent of the infants born. The number of those whose
sight is permanently injured appears to be about 1--20 of those attacked.
Out of 231 cases occurring in the practice of midwives, and followed
up by the medical officer of the London County Council, there was
impairment of vision in 13, of whom 3 w'ere completely blinded
in both eyes. In 40 per cent of the cases there was a history of vaginal
discharge in the mother, and of the mothers of the 13 infants w-hose
sight was permanently injured, as many as 8 had a vaginal discharge.

This report, says Harman, and the official figures given therein, may
-be taken to settle once for all the question whether or no it is advisable
to promote the compulsory use of prophylactic measures, i.e., the use
of a silver salt or other efficient preparation immediately after birth.
No legislature in the world, he goes on, \vould entertain for a moment
an agitation for the compulsory use of a measure for the prevention of
a disease to which no child need be liable, for it is not a disease which
every and any one may contract, and which in London is found to
affect less than one per cent of the new-born, and to injure pennanently
the sight of but one in two thousand. The universal application of
potent antiseptics, with the possibility that they may be carelessly
used, is therefore not called for. The remedy is rather to be sought,
first, in efficient treatment of any vaginal discharge in the mother before
delivery, and secondly, in early notification and efficient treatment of
individual cases of ophthalmia neonatorum as they occur.

Swimming-bath Conjunciiviiis, — In the year 1899 a series of cases

PLATE X]\

TUBERCULOSIS OF 7HE PALPEBRAL CONJUNCTIVA

Iliustration fyoDi iJic J ransixctio?is oj the Ophihainiological Society^ vo/. .i--rrvV7.,
khiitly lent hr J/;. //'. Ornionti anti J'^r, J. //' JL hlyre.

MEDICAL A XX UAL, iQif

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197

CONSTfPATJON

resembling trachoma, but far more easily cured, was traced to infection
in a Berlin swimming-bath b}^ Schultz and Fehr. Another, though less
numerous series of such cases, is related by HuntemiVller and Pader-
stein,® traced to a swimming-bath, also in Berlin. As the water was
changed daity, the towels thoroughly disinfected, and the bath itself
thoroughly cleaned weekly, the authors argue that infection must
have taken place by means of the water itself, infected on the
same day. The habit of rubbing the eyes after diving may have
something to do with it. Pathological examination in these cases
shows that they bear a close relation to true trachoma, and it is
even possible that they actually are trachoma rendered mild by
prompt and efficient treatment.

References. — ’'■Brit. Med. Jour. 1912, ii, 1026 ; ® “Aids to Ophthalmo-
logy/' London, p. 34 ; ^Jour. Amer. Med. Assoc. 1913, ii, 1144 ; ^Ophthalmo-
scope, 1912, 620; ^Pract. 1913, i, >256 ; ^Deut. nied. Wooh. 1912, 2059;
"^Report of Med. Ojf. Health, L.C.C. ioT 1911,80; ^Brit. Med. Jour. 1913. h
1099 ; ^Deut. med. Woch. 1913, 639.

CONSTIPATION. {See also Intestinal Surgery, and Viscei^optosis.)

Robert Hutchiso^i, M.D., F.R.C.P.
The study of constipation b}^ the aid of radiography continues to
engage much attention. From their observations by this method,
Strauss and Brandenstein^ divide cases of chronic constipation into :
(i) Colonic ; {2) Caecal ; (3) Sigmoidal ; {4) Rectal ; according as

the delay occurs in these respective parts of the large bowel. They
admit that careful examination of the abdomen and rectum by ordinary
methods of palpation enables these types to be distinguished without
recourse to the .A^-rays. They do not consider that ptosis of the colon
is an important factor in the production of constipation.

Schwarz^ divides cases according to the supposed disturbance of
function in the colon rather than according to the situation of the
delay. He believes that one can distinguish by this means : (i) A
hypokinetic '' group, characterized radiographically by absence of
the physiological division of the faecal “ column,” delayed entry of the
latter into the pelvic colon, and defective formation of the ” pelvic
globe,” with fragmentary evacuations ; (2) A ” dysldnetic ” group,
'in which the filling of the pelvic colon and the formation of the ” pelvic
globe ” take place in the normal time, but in which an abnormal exag-
geration of the dividing function (hypersegmentation) or of retroperi-
stalsis takes place.

Treatment. — Newburgh® and Gallant^ both recommend a Diet
Rich in Cellulose as a preventive of constipation. The former suggests
the following menu, which, of course, is adapted to American habits : —
Breakfast. — Fruit, apple, grapes, or berries. Cereal : large helping
of oatmeal, cracked wheat or com meal. Eggs, in any form, Graham
or whole-wheat bread, toasted or not, coffee or tea.

Luncheon. — Small helping of fish or meat, with a large helping of
spinach, cauliflower, cabbage, tomatoes, green peas, or beans. Two or
more slices of whole- wheat or Graham bread, or oatmeal crackers.
Dessert as desired.

CONSTIPATION

MEDICAL ANNUAL

I9S

Dinner , — Unstrained vegetable soup. Small helping of meat, fish,
or poultry, baked potato, “ jacket ” and all, peas, beans, spinach, or
cauliflower ; salad, made from lettuce, celery, or asparagus ; bread as
at luncheon ; dessert as desired ; coffee.

Gallant goes so far as to advise the use of coarse, unground, raw
Bran, in quantities of from one to four heaped tablespoonfuls daily.
It may be taken either stirred up in water or mixed with some cooked
cereal. On the other hand, Strauss and Brandenstein, in the paper
already referred to, warn against the danger of exciting a local catarrh
of the bowel by the use of a coarse diet in those cases in W'hich stagna-
tion takes place in certain local areas, e.g., the caecum.

In recent volumes of the Annual, references have been given to the
use of Hormonal in constipation. Sackur® has lately reported on the
effects of an improved form of the preparation. He gave it intra-
venously, and did not find that it produced any bad effects if injected
slowly. It is specially indicated in cases of paralytic ileus and in post-
operative intestinal paralysis and simple atonic constipation. In
spastic constipation it is useless.

References . — "^BevL Min, Woch, 1913, 1009; ^Miinch. nied„ Woch. 1913,
2153 ; ^Bost, Med, and Surg. Jour. 1913, i, 757 ; ^N.Y. Med. Jour, 1912, ii,
.^14; med, Woch. 1913, 401.

CORNEA, DISEASES OF. A, Hugh Thompson, M.D\

• On the whole, the treatment of interstitial keratitis does not seem to
have been much helped by the discovery of Salvarsan and Neosalvarsan
(Medical Annual, 1913. 234). It is true that improvement has
often followed injections of these drugs ; but evidence is lacking that
it has been more rapid than it -would have been without. In Germany,
the local instillation of neo-salvarsan drops into the conjunctival sac
has been tried after some experiments on rabbits, but in the case of
humans the results have not been encouraging. Neither Bachstez,^
working in Prof. Dimmer’s clinic in Vienna, nor Hoelil,- in Hess’s clinic
in Munich, can report any successes by this method.

On the other hand, G. F. C. Wallis^ speaks much more favourably of
his experience of these drugs while he was house surgeon at Moorfields
Hospital. It is only, as a rule, after the administration of the third
or fourth dose, he says, that the cornea begins to clear, the pupils to
dilate, and the ciliaiy injection and photophobia to subside. The
drugs -were administered by intravenous injection at intervals of ten
to fourteen days. Neosalvarsan seems to be quite as efficacious as,
and to cause no more local reaction than, salvarsan. The patients
treated at Moorfields had mercury and iodides in addition, and it must
be remembered that their recovery was probably aided greatly by
several weeks’ residence in hospital, with its attendant hygienic condi-
tions. [This last consideration goes far to discount the specific effect
of the drug. — A. H. T.]

K.EFERENCES. — Hl'/f'//, kliu. Woch, 1913, lox ; -Munch, med. Woch. 1913,
72 ; ‘^Ophthalmoscope, 1913, 342.

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199

DENGUE

COUGH. /. /• Perkins, M,B., F,R,C.P,

Cough, as Mayo Collier^ says, is a symptom so universally associated
with affections of the lungs, bronchi, or larynx that it seldom occurs to
one to look for its cause outside the respiratory tract. The three cases
that he reports are interesting and instructive in that the cough, which
in each was very severe, was not connected with any of the usual
localities. The first case was that of a lady who had been under
treatment without benefit for cough of the severest type, sufficiently
persistent to keep her awake the whole of the night; lungs, larynx,
and post-nasal space were all healthy, the only sign of disease being
a purulent discharge from the left ear. The canal was syringed, and
a large polypus found hanging from the edge of an opening into the
tympanum. The syringing set up an uncontrollable spasm of coughing,
so severe that nothing could be done until cocaine had been applied.
The polypus was removed, and the cough stopped in forty-eight hours.
The second case was that of a lady who suffered from persistent cough,
supposed to be due to gout ; as there was pain shooting to the ear and
under the root of the tongue, the patient was convinced that cancer
was developing. In this case, as in the previous one, the larynx, nose,
post-nasal space, and mouth were all healthy ,* but in the ear on the
painful side there was a large mass of impacted wax, with the removal
of which all the s^miptonis ceased. The third case was that of a woman
who suffered from continual cough day and night, brought up quantities
of blood, was extremely emaciated, and thought, therefore, to be in the
last stages of consumption or cancer of the lung. From the postnasal
space a large polypus was speedily removed, after which the bleeding
and cough stopped and the patient regained excellent health. Moral :
in cases of obscure cough, always examine the throat, nose, and ear,
as well as the lungs.

Reference. — ^Med. Press and Give. 1913, ii, 634.

DEMENTIA PARALYTICA. {See Syphilis, Cerebrospinal.)

DENGUE. Leonard Rogers, M.D„ F.R.C.P.

W. L. Harnett ^ records a number of differential leucocyte counts in
dengue in Assam during the epidemic of 1912. The duration and
character of the fever cases -were very variable, being from two to six
days, and the types from tlnee-day fever of northern India up to text-
book cases of dengue, including the saddle-back type. He agrees
with previous observers in finding a leucopenia w^ell marked after the
second day, with an increase of the large and small lymphocytes but
not of the large mononuclears (hyalines) at the expense of the poly-
nuclears. In addition, he calls attention to a change not hitherto
described in dengue, namely, a variable amount of eosinophilia always
present, and sometimes dominating the picture, which sets in about
the fourth to sixth da5^ is well marked by the tenth day, and persists
for some time afterwards. The average eosinopliile percentage of the
first counts in a series of 24 cases was 1*7, and of later counts 13*4;
in only three cases did it fall below 5 per cent. In several cases the

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fseces were examined for ova of intestinal parasites, with negative
results. Although the eosinophilia occurs about the same time as the
rash, he found no relationship between the degree of the two. This
eosinophilia he thinks is characteristic of dengue, and he suggests that
it may serve to decide the relationship of dengue to three-day and seven-
day fevers. He has not seen a series of cases of seven-day fever, but
encountered three-day fever in Dehra-Dun, in the United Provinces,
and records notes of counts in nine cases showing precisely the same
late eosinophilia as in the Assam epidemic of dengue.

Reference. — "^Ind. Med, Gaz, i9i3> 45.

DIABETES INSIPIDUS. Francis D, Boyd, M,D,

The experimental work of Schafer and his collaborators has shown
that injections of extracts of the infundibular lobe of the pituitary body
have a profound diuretic influence. The renal arteries are exempt
from the general constricting effect caused by posterior lobe extracts
upon other vascular channels and upon unstriped muscle in general.
The diuresis has been ascribed to a direct action upon the renal epithe-
lium, and is independent of the haemodynamic response to the extract,
for it persists long after the secondary fall in blood-pressure and reces-
sion of the kidney to its original size. Cushing^ points out that experi-
mental polyurias can be brought about either by direct operative inter-
ference with the hypophysis, by injection of extracts, or by glandular
implantation ; but hypophysial diuresis may be elicited by stimulation
of the cervical sympathetic passing from the medulla through the cord
to the three upper thoracic nerves. The experimental data then show
that the infundibular lobe contains a chemical body or hormone capable
of eliciting diuresis.

Diabetes insipidus, according to our best known text-books, is sym-
ptomatically defined as a long-continued disorder, characterized by
polyuria and polydipsia, wdth sugar-free urine of low specific gravity.
In the author’s extensive experience with patients who have received
injuries involving the cranial base, polyuria with polydipsia has been
observed in a number of instances. Similar conditions have been
reported by others. In these basal lesions the pituitary body is often
the seat of extravasation, which may readily account for the diuretic
and glycosuric response occasionally exhibited by recipients of severe
cranial injuries. A review of the clinical histories of the published
cases of patients suffering from diabetes insipidus makes it clear that
a large percentage have shown symptomatic evidence of a lesion involv-
ing the base of the brain. Gummatous meningitis affecting the struc-
tures in the middle cerebral fossa is a particularly common accompani-
ment of the disorder. An observation of special significance in this
connection was commented on by Futcher, and has been recently
emphasized again by E. Frank, \dz., the surprising frequency with
which primary optic atrophy, often with bitemporal hemianopsia,
accompanies the encephalic polyurias often classified as diabetes
insipidus. Indeed, diabetes has often been looked upon as a cause of

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DIABETES MELLITUS

the optic atrophy. Cushing gives the clinical history of a number of
cases, and concludes that these observations, coupled with experimental
data, suggest not only that emotional polyurias are in all likelihood the
expression of an urogenic discharge of hypophysial secretion, but also
that clinical po]3mrias of long duration are in many instances merely
the symptomatic expression of an internal secretory disturbance
brought about by injury or disease involving the hypophysial neigh-
bourhood. Hence, our ideas of diabetes insipidus need to be recast
with special reference to the factor of the secretory activit}’ of the
pituitary body, and particularly of its posterior lobe.

Benario,^ in an article on the pathology and therapeutics of diabetes
insipidus, concludes that the posterior lobe of the pituitary body is of
the utmost importance in the etiology. He has collected a number of
cases of disturbance of the hypophysis referable to a gummatous pro-
cess in or around it. The cure of that process, and the possibility of
influencing it by antisyphilitic treatment, are accountable for variability
in the severity of the clinical symptoms. In tertiary syphilis, the naso-
pharynx is primarily affected, and the cause of the polyuria is to be
found in an extension of the gummatous process from this cavity to
the sella turcica and hypophysis. (See also Pituitary Body.)

References. — “^Bost. ISIed. and Snrg. Jour. 1913, i, 901 ; ^Miinch. nied.
Woch. 1913, 176S.

DIABETES MELLITUS, Francis D. Boyd,

At the International Congress of Medicine a discussion took place on
diabetes mellitus.^ The subject was introduced by Dock, who went
fully into the different views that have been published in the hope ,of
clearing up its etiology. The connection of diabetes with the pancreas
was well known ,* perhaps too much attention was paid to the pancreas
in diabetes, and too little to the other organs of the body. The control
exercised by the central nervous system on the sugar-producing function
of the liver w’as better recognized nowadays than it used to be ; the
fact that many spots in the brain, besides the diabetic centre of Claude
Bernard, gave rise to diabetes on puncture was not sufficiently recog-
nized, Cushing’s admirable work on the pituitary gland showed that
its posterior lobe played an important, if indefinite, role in the meta-
bolism of the carbohydrates, and its glycolytic function appeared to be
under the control of the superior cervical ganglion of the sympathetic.
Acidosis, the terminal event that brought on diabetic coma in so many
cases, was connected with decrease in the amount of carbohydrate
in the diet, increased fat-metabolism, and increase in the formation of
sugar from the proteins of the bodily tissues. In the treatment of the
disease, now mainly a matter of dieting, it was important to secure the
attention and intelligent help of the patient.

Von Noorden gave a succinct account of the most recent views of the
way in which the carbohydrate metabolism of the body is regulated.
Needless to say, this regulation was highly complicated, and it was
hard to decide at what point a description of it should begin. However,

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MEDICAL ANNUAt

starting with the intestine, it might be said that it poured the sugar —
glucose — absorbed from the food into the portal vein This glucose
was seized by the liver and stored in the form of glycogen. The liver
retailed this glycogen, converted once more into the form of glucose,
in accordance with the demands made upon it by the tissues. Professor
von Noorden presented to his audience a diagrammatic scheme in
which the control of the glycogenic function of the liver was set out.
The pancreas was the organ that tended to keep the consumption of
sugar down ; the chromaffin system (or, to mention its chief constituent,
the suprarenal gland) tried to increase its consumption. But the
pancreas was in turn controlled by the thyroid gland, the parathyroids,
and the hypophysis ; while the chromaffin system was under the
control of the central nervous system. All these controls, except that
of the central nervous system, were exercised by the medium of the
secretions of the various glands concerned, conveyed about the body
by the blood«stream. The regulation of the glycogenic function of the
liver 'by the pancreas and chromaffin system in the normal subject
was such that the blood contained from 6 to 8 parts of glucose per
10,000. In diabetes this quantity was increased, either because the
inhibiting power of the pancreas was weakened, speaking generally, or
because the augmenting power of the chromaffin system was increased.
In Claude Bernard’s diabetic puncture of the brain, for example, the
glycosuria was due to the central stimulation of the chromaffin system.
Acidosis was fatal, by removing the ammonia and affialine bases from
the body in excessive amounts ; diabetic coma was the expression of
alkaline poverty of the tissues.

Coming to the treatment, von Noorden said drugs were but little
given to diabetics as such nowadays ; the- treatment consisted almost
entirely in setting each patient to live on exactly the diet that suited
him best. A sugar-free diet was first given to reduce the glycosuria to
the lowest possible value ; in favourable cases the sugar disappeared
from the urine. The next step was to ascertain by direct experiment
what was the limit of the patient’s tolerance for carbohydrate ; sugary
or starchy foods were added cautiously to the dietary, and their efiect in
producing glycosuria was carefull}^ watched. These tolerance tests
required the constant supervision and regulation of the physician. It
was most important that the body’s sugar manufactories should at no
time be over-burdened ; the urine must be kept as free from sugar
as possible, or the disease would progress. Too much must not be
expected from such treatment ; there always would be cases that
progressed in spite of the greatest care, because the lesions on which
the disease depended were sometimes inevitably progressive. In
severe cases he advised the adoption of alternating periods of carbo-
hydrate feeding and carbohydrate starvation. Most patients should
have plenty of fat in their diet ; in severe cases, two or three ounces of
whiskey should be given every day. Ten ^^ears ago von Noorden
invented his well-known “ Oatmeal Cure ” ; first the glycosuria must
be reduced by strict dieting, then about half a pound of oatmeal a day

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DIABETES MELUTUS

should be added to the diet for several days in succession. The oatmeal
treatment was found to do good, but for what reason was not under-
stood. Banana cures and flour cures worked on similar lines had
also been employed successful!}^.

Rosenfeld said that many carbohydrates which were not chemically
related to glucose had been tried with varying and inconstant degrees
of success ; glycerin, arabinose, inulin, lactose, and others were specially
to be mentioned. He brought forward a new carbohydrate that
seemed not to increase the sugar production of diabetics, known by the
commercial name of Hediosite ; the name by which it was known to
the chemist was glycoheptonic acid. It was well absorbed ; most
patients could take from one to two ounces of it a day ; many could take
three or four ounces, but the larger doses might set up diarrhoea. It
was a form of carbohydrate that could be utilized and burnt up by the
tissues of even the worst cases of diabetes, and in some unexplained
manner it seemed to lessen the glycosuria.

Knox- points out the rarity of diabetes mellitus in mvly infancy.
Amongst 6496 fatal cases of diabetes occurring in England and Wales
in a decade, there were but 8 under one 3^ear. Knox's patient was
an infant girl, nine months of age. When first seen she appeared well,
but was receiving an unduly large amount of malt soup in her milk
mixture. This was rectified, but a month afterwards the infant was
brought for examination because she was not gaining weight. Sugar
was found in the urine, the disease rapidly progressed, acidosis developed,
and the infant died after an illness of about three weeks. A section
showed the islands of Langerhans diminished in size and number.
Of fifteen collected cases of diabetes under one year of age, the majority
were in males ; heredity seems to have played but little part as an
etiological factor. In three of the fifteen, continuous over-feeding
with sugar preceded the onset of the malady. Injury to, or alteration
of, the central nervous system w'as often associated with the beginning
of the illness. The common symptoms were increased thirst and
hunger, loss of weight, polyuria, and glycosuria ; acidosis and coma
occasionally ended the scene. The prognosis is grave but not hopeless
in infancy, in a severe grade of the disease. Treatment, though difficult
to carry out, should follow the lines found most successful in the
treatment of diabetes in adults — the carbohydrate tolerance should
be determined and the sugar content of the milk mixture corres-
pondingly reduced, the caloric requirements being furnished by fats
and proteins. An “ oatmeal day " or days should be given at
frequent intervals.

Saundby,^ in a lecture on the curability of diabetes, urges that by far
the commonest cause of transitory glycosuria is alcohol, and that its
prolonged abuse may lead to persistent and fatal diabetes. Alcoholic
glycosuria is so common that it is amazing that at the present day
there should be any doubt about it. Alcohol interferes with the
glycogenic function of the liver; a single large dose will do this
temporarily, and the effect soon disappears ; but persistent alcoholic

DIABETES MELLITUS

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MEDICAL ANNUAL

excess maintains this functional depression until ultimately it becomes
permanent, and true diabetes is developed.

An interesting communication by Richards* is on the Wassermami
reaction in diabetes with reference to its relation to acidosis. In this
study, cases of simple acetonuria are not included, but only those in
which oxybutyric and diacetic acids occurred in the urine. Four
cases of diabetes with marked acidosis were examined. In all four,
a marked Wassermann reaction was present on several occasions,
and the reaction was unaffected by anti-syphilitic treatment. Cases
of diabetes were examined in which acidosis was not present and a
negative reaction obtained. Syphilis was not an etiological factor
in any of the cases studied, and the reaction is not indicative of syphilis
when positive in diabetic acidosis.

Beveridge® lays great stress on intestinal stasis and putrefaction as
a primary factor in the causation of pancreatic disease and diabetes.
It is claimed that much benefit may be obtained by treatment by
B. bulgaricus, whose action upon sugar results in the formation of
lactic acid. The necessity for starch as a food is fully recognized ; but
if digestion is unable to break down its molecules, it becomes harmful,
as in glycosurics. By the action of the bacillus, much needed carbo-
hydrate may be taken, with little if any excess of sugar appearing in
the urine. Its chemical action is of great importance when the normal
conversion of sugar in the alimentary tract is at fault, and if an active
culture is given, the liver and pancreas are aided in carbohydrate
digestion. The lactic acid is of practical importance in stimulating
the pancreas when the gastric acidity is low. The action of the bacillus
in combating intestinal putrefaction and autointoxication is marked.
In the milder cases of diabetes' the treatment seems to have been
followed by beneficial results, the symptoms disappearing, but in
others glycosuria remained, though the sugar diminished in quantity.
In the severe cases, results were not so striking. Blodgett® records an
exhaustive trial of the Bulgarian bacillus in six cases, and is unable to
obtain any evidence of benefit from its administration.

Montgomery,’ discussing the frequency of tuberculosis in diabetics,
finds that it is not definitely higher than in the general population.
One is impressed, however, by two facts — ^the lowered opsonic index
to the tubercle bacillus and to a number of other bacteria in diabetes ;
and the large number of diabetics who, late in the course of
the disease, develop a very acute and rapidly fatal form of consump-
tion. Tuberculosis occurs more frequently in diabetes than in some
other chronic diseases, but its frequency varies with many different
circumstances. When diabetes and tuberculosis are associated, the
former can easily be shown to be the primary disease. In no case
in the writer’s experience has tuberculosis been definitely proved to be
primary. From the number of cases that have improved, one cannot
consider a combination of diabetes and tuberculosis as necessarily
more hopeless than either disease alone. The prognosis in many cases
depends largely on treatment.

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DIARRHOEA

Operations on diabetics . — drew attention to the fact that in
diabetics the removal of tumours was sometimes followed by the
disappearance of the glycosuria. His patient was a female who
passed 50 grams of sugar daily in spite of a rigid diet. Hysterectomy
was necessary for uterine haemorrhage. Carcinoma of the uterus was
discovered ; the patient made an uninterrupted recovery, and several
months afterwards was sugar-free in spite of an unrestricted diet.
Joslin reported a similar case, where the removal of fibroid tumours
was followed by the disappearance of sugar from the urine in a patient
apparently suffering from a severe form of diabetes. Manges® reports
two additional cases, both suffering from severe diabetes with advanced
prostatic disease. The first, a man of sixty-two, with long-standing
diabetes and prostatic troubles of several ^^ears’ duration, was considered
a bad surgical risk. Finally, the urinary condition became so urgent
that operation could not be delayed. The operation afforded relief,
the sugar greatly diminished, and acidosis, which had been present,
disappeared. The second, a man of seventy, suffered also from severe
prostatic difficulties, and seemed a bad surgical risk. The patient,
however, made a complete recovery ; the sugar disappeared from the
urine, and never returned in spite of a most liberal diet. It is difficult
to suggest any feasible explanation of the disappearance of the glyco-
suria in these cases. In none of the four was there present a chronic
interstitial nephritis with increased blood-pressure, a condition some-
times associated with improvement or cure of diabetes ; in the four
cases in which operation was required the tumour was situated in the
genital tract. Of more importance than etiological speculations are
the practical conclusions regarding prognosis in operation in severe
diabetes. The sufferers have always been a dread " touch-me-not
for the surgeon, with the result that many have been allowed to die
unrelieved. These cases show that the prognosis, from an operative
point of view, is far better than is generally believed. We may even go
further, and hope that benefit to the diabetes may follow operation.
In general, it may be said that the practitioner and surgeon have too
great a fear of acidosis. When the / 3 -oxybutyric acid tests are negative
there is no danger, no matter how intense the acetone reaction may be.
If the proportion of ammonium nitrogen to total nitrogen is low, the
danger from grave acidosis or coma after operation is not great enough
to contraindicate necessary surgical interference. {See also Gangrene,
Surgery of).

References. — '^La^icet 1913, ii. 54S ; ^ Johns Hop. Hasp. Bull. 1913.
274; ^Med. Press and Circ. 1913, i, 680; *Jour. Anier. Med. Assoc. 1913, i,
1139; ^N.y. Med. Jour. 1913, ii, 70; ^Med. Rec. 1913, i, 1071 ; Amer.

Jour. Med. Sci. 1912, ii, 543 ; ^Jour. Amer. Med. Assoc. 1913, i, 661.

DIARRHOEA OF GASTRIC ORIGIN. Robert Hutchison, M.D., F.R.C.P.

This variety of chronic diarrhoea — also known as " gastrogenic
diairhoea ” — is by no means uncommon, but is still not as well known
to practitioners as it ought to be. It results from a defective secretion
of gastric Juice. The following account of its clinical features from a

DIARRHCEA

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MEDICAL ANNUAL

paper by Van der Hoof^ gives a clear description of it. The most
striking feature of the diarrhoea is its occurrence early in the morning
and during the forenoon. As a rule, it may be said that patients with
this condition are unlikely to have any bowel movements in the after-
noon or at night. It often awakens the individual from sleep at five
or six o’clock in the morning, a second call to stool generally occurs
before breakfast, and one to three movements take place between
breakfast and the midday meal. In other patients, the diarrhoea is
more profuse, with very frequent stools. In some cases the diarrhoea
may alternate with constipation, but often the constipation may be
attributed to full doses of astringent drugs, with which these patients
are so often treated.

The stools are liquid and inoffensive, as a rule, and show the presence
of macroscopic particles of undigested food, especially fruit and vege-
tables. In other cases they are soft and yellow, and show an excess of
fatty-acid crystals. . Mucus and blood are not usually seen, but may
occur during exacerbations. Flatulence and peristaltic unrest are the
rule, especially in the early morning hours. With these there may be
griping pains throughout the abdomen, although most patients are
free from actual abdominal pain. Irritability of the bladder, relieved
after defcecation, is not uncommon.

Gastric symptoms are often lacking, or are overshadowed by the
condition of the bowels. The entire absence of any complaint referred
to the stomach is rather striking. The appetite is generally iinim-
paired, although the patient may be afraid to eat. Occasionally there
is slight nausea, and, curiously enough, the patient may recite the
symptoms of hyperchlorhydria. Loss of weight and strength may
develop quickly after the intestinal disturbance sets in. In other cases,
with distinct weakness and prostration, there may be no diminution of
the body weight. Early in the disease, and in the absence of complica-
tions, the patient does not look ill. Other individuals may show a
marked secondary aniemia, but quite distinguishable from the blood
picture of pernicious aucemia. Indicanuria is pronounced in most
cases. Muscular pains and slight recurring arthritis are not uncom-
mon, or there may be a definite neuritis.

The test breakfast makes a relatively short stay in tlie stomach, which
empties itself so quickly that often no remains can be obtained after
the lapse of one hour. It is advisable to pass the stomach tube in
forty or forty-fi\’e minutes after the breakfast has been taken. The
material obtained shows a characteristic gross appearance. The
bread particles are coarsely divided and show no evidence of having
been acted upon by any digestive agent, and the fluid portion is clear,
thin, and colourless, without visible blood or mucus. The tests for the
presence of free HCl are negative, and the total acidity is usually below
10 “ acidity per cent.”

Treatment. — The chief dietetic indication is the Restriction of Pro-
teins. The author has found Buttermilk up to three pints daily well
borne, and useful where nutrition is impaired. Medicinal treatment

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DfARRH(EA, rNFANTILE

consists in the free administration of Hydrochloric Acid {30 drops of
the official acid in a full glass of water half an hour after each meal,
the dose to be repeated in another half hour).

Reference. — '^Amcy. Jour. Med. Sci. 1912, ii, 170.

DIARRHCEA, infantile. Frederick Lanqmead, M.D., F.R.C.P,

Among the measures commonly employed for the epidemic diarrhoea
of the summer months, Subcutaneous Saline Injections have in the last
few 3^ears taken a prominent place. It is important, therefore, that
their value should be carefully investigated. H. B. Da}^^ records the
results of an investigation conducted by the Public Health Department
of Egypt in the poorest quarters of Cairo. Only severe cases were
selected, and 444 are available for statistical purposes. It was found
impossible to classify them into an^^ etiological or clinical groups.

The following solutions were used : —

1. Quinton’s marine plasma. This consists of sea- water, collected
in sterilized vessels at a sufficient depth and distance from land to
ensure purity, and diluted with sterilized tap-water to make an isotonic
solution. On analysis it yields i per cent of total chlorides.

2. Sea-water collected oil Alexandria, diluted in the same wa3^
This was put up in sterilized bottles, and the whole heated in an
autoclave to ensure sterility. [A step which might injure the utility of
the plasma. It might have been simpfy passed through a Pasteur
filter. — E d. Med. Ann.].

3. Ringer’s solution.

All the solutions are decidedly hypertonic as compared with the
•6 or *75 saline commonly used. During the cooler months, the saline
was warmed by running it tlirough a glass coil immersed in a tin of hot
water, so that it issued from the needle at approximatefy bod 3^ tempera-
ture. The skin at the site of injection was sterilized with tincture of
iodine only. The dose varied from 25 to 150 c.c., according to the
rapidit^^ of its absorption. Improvement was generali}^ manifest after
the first da^^, but unless the injections were continued, a relapse usually
occurred.

Analysis of all the cases treated showed that diarrhoea in the first
few months of life is particularly fatal. Cases with a subnormal
temperature, indicative of collapse, are attended with the highest
mortality ; otherwise the gravity of the illness is proportional to the
degree of fever, although babies with a high febrile reaction to the
saline (104° F.) generally did well. The previous condition of the
patient, and the duration of the illness before treatment, were factors of
considerable importance, affecting more the duration of treatment
necessary than the immediate mortalify. Two series of cases were
treated concurrently, one by injections only, the other by drugs alone,
and the results showed the superiority of the ordinary methods of
treatment by drugs. When vomiting was at all a prominent symptom,
Dilute Iodine Solution (Tinct. lodi TH^iij, Aq. gj) was prescribed, a
small teaspoon fill every two hours, before ea ch feed. This was very

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MEDICAL ANNUAL

successful in checking the vomiting. The most useful medicine was
found to be Calomel combined with Bismuth (Calomel gr. ^ , Bismuth.
Carb. gr. iiss), which gave better results than grey powder. When the
presence of mucus and blood in the stools indicated that the large
intestine was involved, Salines (sodium sulphate or phosphate) were
prescribed with benefit. The addition of a little Tincture of Opium
was valuable in severe cases.

The conclusions arrived at as the result of the investigation were
(i) That saline injections alone, without drugs, are capable of curing
most cases of infantile diarrhoea ; (2) Quinton’s marine plasma has
no definite superiority over artificial saline of the same strength. Such
hypertonic solutions are preferable to those which are weaker (*75 per
cent or less) ; (3) The administration of medicine is preferable to
injections of saline as a routine treatment; (4) Disregard of dietary
instructions is the commonest cause of failure in out-patient treatment ;
and (5) Injections are valuable in proportion as the loss of fluid — by
vomiting and diarrhoea — exceeds the intake. They should be given
before actual symptoms of collapse arise.

Intraperitoneal Injections of Saline are preferred by some. Accord-
ing to C. Miller, 2 it has many advantages : it causes very little incon-
venience, large quantities of fluid may be given in a short time, and it
is rapidly absorbed. To the objection which has been raised, that there
is risk of wounding the intestine, he replies that he has never seen this
happen. He inserts the needle through the abdominal wall just below
the umbilicus. The good results in his experience are very striking.

The majority of pediatrists consider complete abandonment of
milk to be the most essential point in treatment. Clock, ^ however,
strongly combats this practice, stating that a starvation diet accom-
panied by purgation is productive of loss of weight and strength, and
serves to prolong its course. He considers that the results which he
has obtained in 117 cases by implantation of the Bacillus Lactis
Bulgaricus corroborate his view ; 116 recovered and i died ; 72

returned to the dispensary during the winter for some other affec-
tion, and 41 of the remainder 'were able to be traced and found to
be in good health. The babies’ ages varied from six weeks to two
and a half years, and the average time from the onset of the disease
until the treatment was started was one week. It consisted in the
administration of a pure culture of the true Bulgarian bacillus, first
described by Grigoroff. It was prescribed in tablet form, i or 2
tablets being given every two or three hours in most cases, but 2 or
3 every two or three hours before and after each feeding in severe
cases. Seventy-four infants were continued on their respective milk
diets, and 43 were placed on barley-water for twenty-four or forty-
eight hours, after which smaU quantities of boiled, skimmed, or whole
milk were usually added to the diet. Twenty-nine of the 43 were given
a preliminary dose of castor oil, but no cathartic was used for those
kept on milk. Improvement b}’^ this method of treatment was shown
by gain in weight, rapid change in the character of the stools to normal

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DIPHTHERIA

colour and consistency, improved appetite, subsidence of fever, abate-
ment of vomiting, and a healthier appearance. The babies who were
allowed milk showed an average gain in weight, during the first
twenty-four hours, of onl}^ half an ounce less than the average gain
in the entire first week by those for whom milk was interdicted. In
his opinion, it is the lack of a pure, active culture of the bacillus in
viable form which has been the cause of the iiidifierent results obtained
in previous years with lactic-acid bacterial therapy.

References. — ^Pract. 1913, ii, 58; ^Lancet, 1913, ii, 774; ^Jouy. Amer.
Med, Assoc. 1913, ii, 1O4.

DIPHTHERIA. E, IV. Goodall, M.D.

Pathology. — ^An account of three cases of diphtheria of the oesophagus
has been published by J. D. Rolleston,^ and one of diphtheria of the
stomach by F. E. Tylecote.^ Both these conditions are rare. In the
former the lower third of the oesophagus was involved, in the latter
nearly the whole of the stomach. Perhaps if a more systematic
inspection of the organs was made in autopsies, it would be found that
their involvement by diphtheritic membrane was not so rare as it
appears to be. RoUeston, indeed, quotes Mallory as stating that the
oesophagus was involved in 12 out of 251 autopsies (47 per cent), and
Tylecote refers to Councilman, Mallory, and Pearce’s experience at
Boston ; these observers found the stomach involved in 5 out of 220
fatal cases. But even when the stomach is invaded, it is rarely so
completely as in Tylecote’s case. Unfortunately the condition cannot
be diagnosed during life, unless the patient vomits a cast of the organ.
Both papers contain full references to previously recorded cases.

Treatment. — Although it is nearly nineteen years since the Anti-
toxin treatment of diphtheria was introduced, there is still considerable
diversity of opinion on the question of dosage, even amongst those who
have had a large experience. W. H, Park® quotes various- authorities
as recommending doses up to maxima which differ so widely as 6,000
and 400,000 units. He refers in some detail to clinical observations
which lead him to state that '' amounts of antitoxin beyond 25,000
units in a child, and 50,000 in an adult, are absolutely unnecessary and
useless ; and that an initial dose of 10,000 in a child and 20,000 in an
adult is probably sufficient for the whole course of the disease,” He is
of the opinion that it is important to give all the required antitoxin
promptly, and usually in a single dose, because experiments on
animals and observations on human beings go to show that antitoxin
given by subcutaneous injection is absorbed very slowly. In some
patients antitoxin formation goes on rapidly, excited by the toxin
produced in the diseased tissues, to add its amount to that given. In
the chart of such a child w^e notice at first the usual slow absorption
which by the end of a day is but half a unit [per c.c. of blood] ; suddenly
the antitoxin formation begins, and the child has, by the end of the fifth
day, 60 units in each c.c. of blood, and at least 90 per cent of this is due
to its own production. This was the only cluld tested who made such

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a IreineiidoLis ainoimi oX antitoxin ; uiosi children produce compara-
little. The important fact is that what we give subcutaneously
on the hrst day is rendering the body fluids more and more antitoxic
until the third or fourth day.*’ -

The author thinks that weight and size arc of importance in influenc-
ing the magnitude of the dose. ** If we give two children, one of 40 lb.
and one of 80 lb., a certain amount of antitoxin, the larger child will
have approximately one half as much antitoxin in each c.c. circulating
in the blood as has the child of half the size. I think there can be no
question that it is chiefly the concentration in the blood and not the
total amount which measures the effect.” By the intravenous method
of administering antitoxin the wdiole amount is launched into the
blood at once. This method, therefore, should be resorted to in severe
cases. Intramuscular injections are absorbed in about half the time
required by subcutaneous injection ; but the serum often escapes from
the muscle into the suiToimding tissues.

In the last volume of the Annual an account was given oi Schiotz’s
method of treating diphtheria carriers by Spraying or Swabbing the
fauces with Bouillon Cultures of Staphylococcus Pyogenes Aureus.
Additional reports of cases treated in this way are now to hand. J. D.
Rollestoii'^ reports 10 cases ; F. L. Wright,® several (exact number not
stated) ; and A. M. Alden,® 16. The latter states that 15 cases were
cleared in a few days of diphtheria bacilli after other methods had been
unsuccessfully employed, but that in one case the method absolutely
failed. Wright’s experience was obtained in the New York State
Agricultural and Industrial School, in which there were about 740
boys of ages ranging from six to seventeen years. The school was
much troubled with carriers, mostly introduced from outside. Wright
states that in his hands the method ’was innocuous and capable of
causing early disappearance of the bacilh. Rolleston’s patients were
convalescing from diphtheria. In six faucial cases the diphtheria
bacilli disappeared in two to seven days ; in two nasal cases the treat-
ment was ineffective. Apparently, in the remaining two cases the
bacilli disappeared only after a considerable period. In eight of the
cases a mild forxn of sore throat was produced ; and either this effect
or slight nasal catari'h was set up in six of Alden’s cases. Clara M.
Davis'^ reports a case in which well-marked follicular tonsillitis occurred,
apparently as the result of the treatment. Rolleston writes that as
the process entails some degree of discomfort, it is well not to employ
it until other methods have been tried,” and for that reason he apiDlied
it only to chronic carriers in whom the bacilli had been present for more
than six weeks. He also gives reasons for not using it except at a late
stage of convalesence. (i) In the early stage the mucous membrane
has not recovered from the effects of the attack of diphtheria ; there
is still a breach of the surface which would render the deeper tissues
liable to invasion b}^ pyogenic organisms. (2) The excess of mucus
and detritus present during the acute stage shelters the diphtheria
bacilli from the action of the staphylococci. (3) Since most of the

NEW TREATMENT

2II

DIPHTHERIA

patients must be detained in hospitals owing to the possibility of
complications, it is unnecessary to resort to the treatment early.
RoUeston quotes certain experiments of Lydia de Witt,*^ which
suggest that the apparently favourable action of the staph}'lococci
is due not to an incompatibility between the two organisms, but
to a reinforcement of the normal throat flora.'’

Harold B, Wood^ reports four cases in which it seemed that a Spray
of the Bacillus Acidi Lactici was efficacious in ridding the fauces of
diphtheria bacilli.

R. Tanner Hewlett^'^ has published another case of the apparently
successful treatment of a carrier by his method of the subcutaneous
injection of Diphtheria Endotoxin.

[These results are referred to here because it is the commonly held
opinion that most diphtheria carrieis are highly dangerous to the
community. This is not my view. Though occasionally a carrier
appears to, and most likely does, do harm, by spreading the disease,
yet the danger attributed to them is much over-estimated. Again,
whether the treatment by the Staphylococcus pyogenes aureus really
performs all that is claimed for it, still remains to be proved. In
most cases of diphtheria the bacilli disappear naturally after a few
weeks, without any treatment. — E. W. G.]

Prophylaxis. — ^The production of active immunity against
diphtheria by injection of a neutral or nearly neutral toxin-antitoxin
mixture has long been practised. Hitherto it has been believed that
if a guinea-pig, the animal which is most commonly employed in
experiments of this nature, could resist any particular mixture, so also
could any other animal. But \’on Behring^^ has recently shown that
this is not the case ; but that a mixture which is non-toxic for guinea-
pigs may produce well-marked reactions, with formation of antitoxin,
in other animals (donkeys and monkeys), and also in the human subject.
He has further found that persons w’ho, having suffered from diphtheria,
already have antitoxin in their blood, are especially susceptible to the
action of the mixed toxin and antitoxin, and that in them the injection
of the mixture quickly produces additional large amounts of antitoxin.
His new" prophylactic against diphtheria (‘' diphtherieschutzmittel ”)
he describes as being a mixture of very powerful diphtheria toxin and
antitoxin in such proportions that experiments on guinea-pigs show
that it contains only a trifling or very small excess of toxin. In the
discussion on immunization against diphtheria wdiich took place at
Wiesbaden last April, IMattlies, of Marburg, reported a case in w-hich
the subcutaneous injection of c.c. of Behring’s mixture gave rise to
an antitoxin production of more than Coo,ooo units, wiiereas 250 units
would have been quite sufficient to secure immunity. The serum from
this case w^as used to immunize passively another patient, a child.
It w"as stated that the passive immunity thus induced was of much
longer duration than that brought about by ordinary antitoxic serum,
wffiich is obtained from horses. As in this case the injection consisted
of an anthropogenous serum, the risk of the excitation of anaphylactic

DL^HTHERIA

212

MEDICAL ANNUAL

symptoms by any subsequent injection of serum is absent. The
observations of Schreiber^‘^ and Zangemeister^® (who immunized certain
gra\id women and new-born infants in the women’s hospital at
IMarburg) go to show that Behring’s new prophylactic is both efficacious
and harmless.

References. — Jour. Child. Dis. 1912, 12 and 1913, 405 ; -Ibid,
1913, 21 1 ; ^Bost. Med. and Surg. Jour. 1913, i, 73 ; Jour. Child. Dis.

1913, 298; ^Jouv. Amer. Med. Assoc. 1913, it 26; Mbid, t 1S76 ; Mbid, it
393 J ^Jour. Infect. Dis. 1912, 24 ; ^Jour. Amer. Med. Assoc. 1913, ht 392 ;
^'^Lancet, 1913. t 1S02 ; ^^Deut. med. Woch. 1913, S73 ; '^Mbid. 928 ; ^Mbid.
977 *

DIYERTICUHTIS. Robert Hutchison, M.D., F.R.C.P.

Diagnosis, — From a study of twenty-seven cases operated upon
at the Mayo clinic, Giffin^ draws the following conclusions. Given
a patient with a tumour of the sigmoid, the points in the evidence
which would favour a diagnosis of the chronic proliferative type of
diverticulitis are as follows : (i) The absence of shadows of malignancy
in the general picture ; (2) A tendency to obesity and the maintenance
of good nutrition ; (3) A long history of attacks of low abdominal
pain localizing in the left lower quadrant; (4) A history of [the
previous formation of a mass and its subsequent disappearance ;
(5) A failure to obtain a more or less continuous history of the frequent
passage of macroscopic blood in the stools ; (6) The demonstration of
vesical hstulae wdiich, on cystoscopic examination, appear to be inflam-
matory ; and (7) The failure to demonstrate malignancy positively by
sigmoidoscopic examination.

In carcinoma of the lower bowel there is usually an early loss of
flesh. Pain is not a prominent feature until obstruction advances,
and the mass is often found before pain has been complained of at all.
Tenderness to pressure is a late finding. The relative frequency must
also be kept in mind. Carcinoma of the sigmoid is about seven times
as frequent as diverticulitis.

The other inflammatory forms of perisigmoiditis cannot be positively
differentiated. A diagnosis of appendicitis in cases of transposition
of the viscera should not be difficult. If non -rotation of the colon exist,
a radiographic or fluoroscopic examination after a bismuth meal would
be necessary\ It must not be forgotten that a pelvic tumour may be
sigmoidal, and the possibility^ of diverticulitis is to be considered.
Pelvic inflammatory disease may’ be closely simulated. In fact,
diverticulitis should be carefully considered in the diagnosis of all
tumours of the left lower abdominal quadrant and of the pelvis.

Reference. — ^Joiir. Amer. Med. Assoc, 1912, ii, S64.

DUCTUS ARTERIOSUS, PERSISTENT.

Carey Coombs, M.D., M.R.C.P.

Three papers — by Miller and Orton, ^ Wessler and Bass, 2 and Motz-
feldt® — describe examples of this condition. It is fairly common as
congenital defects go, occurring in about one-quarter of all cases of
cardiac malformation, though as an isolated fault it is much rarer.

NBW TREATMENT

213

DYSENTERY

Unless accompanied by otlier defects, patency of the dnctus Botalli
produces no s^’mptoms. In none of ]Motzfeldt*s three cases was there
any clinical evidence of a cardiac anomaly, and it was only discovered
at autopsy. In only one of five cases reported by Wessler and Bass
were subjective symptoms complained of, while in that published by
Miller and Orton they were not prominent. The ph5rsical signs are a
strip of dullness along the upper part of the left parasternal region,
loud systolic murmur maximal at the second left interspace and pro-
longed into diastole in
adults, and a charac-
teristic alteration of
the cardiac ;v-ray
shadow, which is con-
tinued upwards along
the left sternal border
as high as the sterno-
clavicular joint [Fig.

17). Miller and Orton,
and Wessler and Bass,
lay great stress on this
latter phenomenon,
which is probably due
to dilatation of the
pulmonary artery.

The pulmonic second
sound is sometimes
very loud, and a thrill
may be felt in the
neck. It is important to recognize the nature of the defect when its
signs are encountered, lest an unduly alarming pronouncement of
serious cardiac disease be erroneously made.

References. — Jour, Child, Dis. 1913. 109 ; -Jwer. J>ntv. Med,
Sci. 1913, i, 543 ; ‘^Deui, 7ned. Woch. 1913. 2037.

DYSENTERY. [See Amcebiasis.)

DYSENTERY, FLAGELLATE. Leonard Rogers, M.D„ F.R.C.P,

Melli-Leitao^ discusses the vexed question as to whether flagellates
can produce dysenteric symptoms. Contrary to the opinions of most
authorities, he maintains that they can do so in children, the incrimi-
nated varieties being the Trichomonas intestinalis of Leuckart and
Lamhlia intestinalis. He reports seventeen cases of diarrhoea with
mucus and even a little blood in the stools, but without griping or
straining, and containing very numerous flagellates, which become
encysted as the stools improve. The disease is acute, but easily cured
by 7 per cent Magnesium Sulphate and water or milk diet. Sometimes
enemata of i per cent Collargol or Electrargol are required.

Reference. — Jour, Child. Dis. 1913, 60.

DYSPEPSIA OF CHILDREN

214

MEDICAL ANNUAL

DYSPEPSIA (INTESTINAL) OP CHILDREN.

Fredevick Langmead, M.D,, F,R.C.P,

Cautley^ recognizes the following forms : —

(1) Simple intestinal dyspepsia and sub- varieties : {a) Food fever ;
{b) Mucous disease.

(2) Catarrh of the small or large intestine, or of both : (a) Mucous
disease ; (6) Chronic enteritis or ileo-colitis ; {c) Catarrhal or mucous
colitis.

(3) liepatic inadequacy or dyspepsia ; {a) Hyposecretion of bile ;
(6) Overloading of the liver with fat or glycogen.

(4) Pancreatic inadequacy.

These various affections cannot strictly be demarcated one from
the other ; two or more may be present together in the same patient,
and one may develop into another.

Acute intestinal dyspepsia begins suddenly, with fever. It is charac-
terized by severe colicky pains about the navel, frequently by tym-
panites, and is followed by diarrhoea in a few hours. It is often called
“ belly ache," and is quickly cured by castor oil or an enema. It is
apt to be regarded as appendicitis, but is more common in infants than
in older children, and is liable to occur in diseases of the lung or pleura.

Chronic intestinal dyspepsia of the simple type may follow an acute
attack, or come on insidiously, with loss of appetite and flesh, languor,
debility, restlessness, and irritability. The child is disinclined to get
up in the morning, and seems lifeless during the day. In the early
part of the night there may be restlessness, teeth-griiicling, somnilo-
quence, pavor, somnambulism, and night-sweats, followed by deep
sleep. Frontal headache is often present in the morning and after
school. The children are nervous and excitable ; and some are liable
to violent and prolonged outbreaks of temper. Curious attacks of
pallor ai'e a common and characteristic feature, and the child experi-
ences a feeling of faintness, but actual syncope is rare. At the same
time the hands and feet are cold, and there may be colic. Such attacks
are probably due to enterospasm or intestinal distention, and must be
distinguished from actual fainting attacks and from petit mal.

The child is pale or sallow, with perhaps a slight icteric tinge or
actual jaundice, and has dark rings under the eyes. There is obvious
malnutrition, accompanied by soft flabby muscles, although the face
is not wasted. The chest looks flattened by contrast with the pot-
bellied abdomen. The skin is harsh and dry in severe cases, and the
extremities are generally cold. The tongue is often pale, flabby, and
indented, with a yellowish-wlxite fur on the dorsum far back, whilst
anteriorly it is covered with mucoid secretion. The appetite may be
poor, lost, ravenous, or perverted. The breath may be foetid. Vomit-
ing, if present, is due to an exacerbation which is often described as a
" bilious attack," or " an attack of gastric fever." The stools are
generall}^- normal in appearance ; but may be grey, and very offensive,
or large, offensive, and composed of scybala. There may be frequency
or looseness. Mucus is commonly present. The urine contains an

NEW TREATMENT

215

DYSPEPSIA OF CHILDREN

excess of urates, and there may be cyclic albuminuria. Fever is
absent, except during exacerbations.

The condition is most common in children during early school life
and the second dentition. Boys are more liable to it than girls. Excit-
ing factors include defective teeth, and unsuitable diet, hurried meals,
insufficient rest, late meals and late hours, and too stimulating amuse^
ments. Overstrain, mental and physical, and over-anxiet3^ are also
concomitant causes. The main cause is probably an error in diet,
more especially an excess of milk and starchy foods, for regulation of
diet in this respect quickly cures many cases. Large tonsils and
adenoids are often present, and chronic pharyngitis almost constantly ;
but these abnormalities should be regarded as contributory causes,
rather than as effects.

Carbohydrate or food fever Cautley does not regard as an entity". It
is a name given to acute febrile attacks, with anorexia, headache, and
general malaise. The attacks yield readily to a mercurial purge, and
have in some cases been cured b^?' strict limitation of carbohydrate
foods.

Mucous disease he regards as a form of intestinal dyspepsia, in which
there is a hypersecretion of mucus from the mucous membranes of the
alimentary?’ tract, the nasopharymx, the respiratory, and, occasionally,
the urinary tract.

In hepatic inadequacy there are white or clay-coloured stools, com-
plete acholia without jaundice, and occasionally’’, cy^stinuria. The
excretion of uric acid is decreased, and that of indican increased.
Sometimes the liver is swollen, and jaundice may occur. It n^ay be
the first stage of recurrent vomiting." Cautley^ considers that the
"acholia" described by Cheadle, and the "cceliac disease " of Gee are
the same disease. It is common under two, and rare over four yrears
of age : the stools resemble those of obstructive jaundice : they? are
acid, or slightly alkaline ; glistening and greasy, often f^othy^ very^
offensive, and larger than normal. The other symptoms are those of
intestinal dyspepsia.

Pancreatic inadequacy is characterized by large stools, colourless,
and acid from excess of unsaponified fat, chiefly as fatty acids, and
containing abundant stercobilin. The main synnptoms are anaemia,
emaciation, abdominal distention, and a liability to sore tongue,
aphthae, and ulcers. Prolonged cases lead to infantilism. Milk diet
is useless, and the child must be fed on nitrogenous and dextrinized
foods.

In achylia gastrica the chief signs are good appetite, malnutrition,
abdominal pain, and diarrhoea. The stools are liquid, pultaceous,
fcetid, and clay-coloured. They contain meat fibres and trypsin, no
starch, and little fat, fatty acid, or connective tissue.

Diagnosis. — Microscopical examination of the stools is of very
great value, and the odour, colour, reaction, consistency, and pre-
sence or absence of mucus afford considerable assistance. If the stools
are apparently normal, the child may be treated for simple intestinal

DYSPSPS5A OF CHILDREN

216

MEDICAL ANNUAL

ci;’-spepsia. If they are white, one should ascertain whether the
al:»sence of colour is due to excess of milk curd, complete absence of bile,
ccnverslon of bile into urobilinogen, or excess of fat. Worms and the
simpler causes of colic must be excluded.

Treatment. — General, — In severe cases, with marked neurotic
symptoms, a few days in bed is a useful preliminary. Prevent over-
strain, physical or mental, and forbid working for examinations.
Change of air and surroundings cures many cases quickly. Keep the
abdomen and extremities warm and dry. Attend to the teeth, and
remove enlarged tonsils and adenoids if present.

The diet should consist of simple, regular, mixed meals. Reduce
milk, if it is in excess, and dilute it. Limit the amount of fermentable
foods, sweets, jams, and carbohydrates generally. It is rarely neces-
sary or advisable to omit them entirely. Malted and dextrinized foods,
and honey, are the most suitable carbohydrates. At first the diet
should be limited to eggs, fish, meat, bacon, butter and dripping, dry
toast, rusks, and malted foods. Greens, passed through a sieve, and
ripe fruit, may be added later. New bread, new potatoes, fried fish,
hot greasy foods, pickles, tubers, and stringy vegetables, must be
avoided. Cream suits a few children, and is best given with stewed
fruit, but Cautley has found butter, margarine, bacon fat, and beef
dripping the best forms of hydrocarbons.

Medicinal, — Cod-liver oil and hypophosphites are contraindicated.
If there is constipation, especially if there is also mucus in the stools, give
Grey Powder, or Rhubarb and Soda at night, and a dose of Sodium
Sulphate or Apenta Water in the morning. He recommends a mixture
of Alkali, Nux Vomica, and a Vegetable Butter to be taken three times
a day before meals. Maltine and Mild Alcoholic Drinks he considers
useful. Other appropriate remedies are Bismuth and Carbonate of
Magnesia for diarrhoea ; Charcoal and Salol for tympanites and excess
of mucus ; Decoction of Aloes (J to i dr.) before food for voracious
appetite ; Calomel for white stools ; and small doses of Dover’s Powder
or Tincture of Opium for lientery.

More reliance should be placed on dietetic measures than on drugs,
and attention should be paid to general hygiene, sleep, exercise, and
amusements.

Reference. — "^Med. Press, and Circ. 1913, i, 194.

EAR, DISEASES OP. (See also Ear, Syphilis of; Labyrinthitis;

Otitis Media ; Otoscxerosis ; Tinnitus, and Vertigo.)

Geo. L. Richards, M.D,

Page^ reports a case of congenital bilateral microtia with total
osseous atresia of both external auditory canals, in which improve-
ment was attained by an operation opening up the auditory canals.

Citelli^ divides the common polypi of the ear into two classes, granulo-
matous and neoplastic. The first are of a reddish colour and granular
surface, consist entirely of granulation tissue, and indicate a diffuse and
severe lesion on the walls of the auditory canal. The neoplastic polypi

NEW TREATMENT

217

EAR DISEASES

are of a greyish transparency, with the structure of true fibromata,
fibro-angiomata, and myxomata, have a favourable prognosis, and are
much less common than the first. Both classes of polypi are always
secondary to a latent or manifest inflammation of the walls from which
they originate, and can be transformed from one into the other class.
For this reason it is a question whether to consider an aural polyp an
inflammatory or a neoplastic by-product.

In order rapidly to abort cases of fumnciilosisy Zograffides-*^ disinfects
the external canal cells and pinna, and then makes from three to five
cuts at the point where, with the probe, he has previously found the
greatest pain ; he then applies a sterile strip of gauze moistened in 10
per cent carbolic acid solution. He anaesthetizes the place with cocaine.
The pain lasts from one to tvm hours, but has completely disappeared
in five or six hours after the time of incision.

Yearsley^ emphasizes the importance of classifying pain in the ear
before beginning treatment. If there is neither deafness nor inflam-
mation, it is usually due to some reflex cause, such as irx'itation from a
carious tooth or disease of the tongue or tonsil, and usually clears up
a.fter its removal. Pain accompanied by deafness and inflammation
may be caused by foreign bodies or collections of cerumen in the ear,
which are easily detected upon examination. When the pain is not
severe, the trouble is in the external meatus, ^vhich is red, swollen, and
tender, its walls being covered with a slight amount of discharge, with
fragments of macerated epithelium, while the introduction of the
speculum causes moderate pain. The predominant organism is a
streptococcus. Circumscribed otitis externa causes more marked
symptoms, paroxysmal and severe pain, worse at night, and usually
preceded by irritation and itching in the meatus. With pain in the
middle ear, there is usually more or less deafness from the beginning,
and the condition may be due to a simple acute inflammation of the
t3nnpanic membrane, to acute catarrhal otitis media, or to acute
middle-ear suppuration. Acute middle-ear inflammation begins with
sudden pain, ushering in fullness, obstruction, and tinnitus. In the
early stages the deafness is slight, but increases as exudation takes
place. The pain is violent, most severe at night, radiating over the
side of the head, and intensified by movements of the jaw. There may
be some constitutional disturbance, accompanied by fever, espccialty
in children. When the condition docs not pass beyond that of a
simple catarrhal type, the symptoms arc soon at their height, and
remain so for twenty-four to forty-eight hours, and then quickly
disappear. In more severe cases of acute tympanic catarrh, there may
be perforation of the membrane, and the symptoms abate with its
appearance. When the process is suppurative, the symptoms are much
more severe from the onset, and are often accompanied by constitutional
disturbances, fever, and rigors. Vertigo, delirium, and cerebral
symptoms may appear, and in children may be mistaken for meningitis.
With the appearance of perforation and purulent discharge comes
relief.

BAR DISEASES

218

MEDICAL ANNUAL

Acute deep mastoiditis may be a complication of either acute or
chronic middle-ear suppuration, and calls for prompt relief. The pain
is of a deep, throbbing, boring character, increased by pressure or
percussion.

Functional and Simulated Affections of the Auditovy Apparatus . —
Hovell^ states that simulated deafness by the malingerer is found to
be of sudden onset, usuall}^ noticed when he is alone or upon awaken-
ing in the morning. There is no altered modulation of the voice, and
there is absence of the quick movement of the eyes found in deaf
people when trying to catch the knowledge they usually derive from
tlie sense of hearing. To detect simulated deafness, the examiner
may talk of the patient’s condition in a conversational voice, expressing
sympathy for his condition, and while carrjung on the conversation he
may ask the patient to put out his tongue ; the patient, taken off his
guard by the seriousness of the examiner’s tones, may at once do so.
A test for supposed unilateral deafness is to close the normal ear wdth
a cotton plug and to place a vibrating tuning-fork on the vertex. An
impostor -will assert that he does not hear the sound at all, whereas
the perception must be decidedly increased in the closed ear. Perhaps
he may assert that he hears it faintly on the deaf side. The deaf ear
should now be closed ; the sound ought to be strengthened, and the
assertion that it is no longer heard will prove the imposition. Another
test is by means of the watch and speech. The eyes are bandaged
and the hearing distance is carefully determined. The sound ear is
then apparently closed by a cotton pledget placed in the meatus.
When tested with the watch and voice as before, the malingerer will
say that he hears nothing in the closed ear, whereas the cotton-wool
ill the meatus will but slightly affect the hearing distance. (See also
Maungering.)

References. — ^Ami. Otol. 1912. Dec.; Hbid.\ ^Wien. klin. Wuch, 1912.
Dec. ; *Clhi. Jour. 1913, Apr. ; ^Jour. LaryngoL 1913, Sept.

EAR, SYPHILIS OP. Geo. L. Richards, M.D.

Love^ concludes, from an extensive study of syphilis and its relation
to deafness in children, that the Wassermann reaction or test nearly
alwa^^s gives a positive result when the combination of keratitis
(blindness) and deafness occurs in the child of syphilitic parents.
Occasionally the result is negative. It sometimes gives a positive
result in the apparently healthy brothers and sisters of those affected
by blindness or deafness, thus showing that they are really infected,
and that at a later date symptoms may develop. The commonest
cause of death among these syphilitic children is meningitis, which
occurs most commonly during the first and second years. Untreated
or insufficiently treated syphilis in the parent may be discovered by
the Wassermann reaction many years after infection. Healthy and
diseased children may be born at an}^ stage of the family history, but
the usual family record is that the earliest children are still-born, then
diseased children, and, lastly, healthy children. The later children

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EAR, SYPHILIS OF

have the best chance to live. These conclusions were based on the
examination of the blood of 150 persons, about half of whom were born
deaf, and a third of whom have become deaf since birth. The remain-
ing cases were not deaf at all, but were related to others in the list who
are deaf.

In some families the cells which form their make-up are so deficient
in those determiners or factors which go to the complete development
of a perfect nervous system, that the children born into them
are feeble-minded, epileptic, or deaf. These defects may be accentu-
ated by such poisons as alcohol and sj^hilis. Within the family
stream the defect is permanent, and is developed to its utmost by the
intermingling of similar cells or by the marriage of those who are
related by blood. The defect may become less frequent by streams
or families uniting, one of which is perfect or free from the defect ;
but it cannot be stamped out so long as the family goes on at all, and
the practical question is whether it is so serious for the individual and
for the community that the latter should take steps to protect itself.

Luders® thinks the external and middle ear and labyrinth are liable
to syphilitic infections as well as other parts of the body. Middle-ear
infections of syphilitic origin, like those of tuberculosis, do not show
any specific character. The principal symptom is a more or less sudden
and increasing loss of hearing, sometimes accompanied by dizziness.
The author reports five cases, in four of which the ear phenomena
occurred in two to six years after acquisition of infection, the fifth
being a case of hereditary syphilis. Facial paralysis on the same side
as the affected ear supervened in one case ; in one case, fever, nausea,
vomiting, dizziness, and nystagmus were present. The author believes
that in all his cases the disease manifested itself in the form of
a gumma of the middle ear. Treatment, consisting of Paracentesis
when indicated, plus vigorous antisyphilitic measures, proved efiective
in nearly all cases. In one, Neosalvarsan was emplo^^ed, 0*4 gram being
injected six times at ten- to t\velve-day intervals, with good results.

Theimer,^ since the introduction of the Salvarsan treatment, has
noticed that a not inconsiderable number of cases have been described
in which injury to the internal ear had to be recorded. These affections
are of the internal ear, of the vestibular or of the cochlear apparatus
alone, or of both together, in patients who are already subjects of an
aural lesion. In some of these cases the phenomena disappear in the
course of time, some after repeated salvarsan injections, some after
mercurial treatment. In others the lesions proved to be permanent.
In affections of one or both sections of the internal ear in persons whose
ears have been previously proved to be normal, if the phenomena
appear a long time — weeks or months — after injection, the symptoms
may disappear after a time, or they may persist. If appearing immedi-
ately or shortly after the injection, they persist for a long time, and
may prove to be permanent. There is also an affection of the internal
ear, attacking by preference the vestibular apparatus solely, which
appears immediatel}^ or soon after the injection, and disappears as

EAR, SYPHILIS OF

220

MEDICAL ANNUAL

rapidly, at most within a few days, and so completely that the
phenomena become absoluteh? normal again. The only cases of
injiir^r to the internal ear after salvarsan which can be described as
manifesting the Herxheimer reaction, ai'e those in which the phenomena
appear shortly after the injection and rapidly disappear. The disturb-
ances affect the vestibular portion of the nerve for the most part, and,
as a rule, induce the clinical appeai*ances of a complete paralysis of the
vestibular apparatus,

Rimini‘S reports eight cases where ear trouble came on four to eight
weeks after salvarsan, with such symptoms as a high degree of deaf-
ness, noises, dizziness, and oscillator}? nystagmus, varying in degree and
situation in different individuals. He thinks that syphilis is much
more sensitive to salvarsan than to mercury, and that this accounts
for the fact that similar symptoms were not noticed when mercury
was used. In the use of salvarsan the reaction is greater, and they
become more noticeable. Great care should be used in regard to the
administration of salvarsan in the presence of chronic middle-ear
catarrh and in otosclerosis.

References. — ^ Glasg , Med, Jour, 1913, Feb. ; ^Deid. med, Woch. 1913,
Jan.; '^Lavyngol, 1913. May; ^Deut, med. \Voc/i, 1913. Jan.

ECZEMA. E. Graham Little, M.D,, F.R,C.P,

Etiology, — Lancashire^ classes among predisposing causes of
eczema, constitutional diseases, e,g., Bright’s disease and diabetes,
any debilitating illness, nervous causes such as anxiety, excitement, or
worry, alcoholic and alimentary excess, autointoxication from con-
stipation, dyspepsia, and gout, “ Seborrhoeic eczema ” he does not
regard as properly included in this group of disease.

Treatment. — \Vhen any of the causes detailed above are present,
they must be treated secundum ariem. In the local management of
eczema, it is important to secure protection for the skin. In acute
eczema with discharging surfaces, lotions or dusting powders are
indicated, and Lead is the most widely useful drug to incorporate in
these. A to i per cent solution of Aluminiura Acetate or a ^ per cent
solution of Silver Nitrate is a serviceable lotion. Where there is pus
infection of the surface, Carbolic Acid or Cresol Saponatum may be
added to the lotion. In chronic eczema, ointments and paste are
more generally useful. A good formula is zinc oxide i part, starch
I part, soft paraffin 2 parts ; to this may be added Lenigallol (5 per
cent). Careful and persistent dressing is required ; in very chronic
and indurated forms. X-rays are often very effective. Acute and
widespread cases should be kept in bed. Biilkley’s Rice-Diet (rice,
bread and butter, and water) is especially useful in reducing inflamma-
tion and itching. In ansemic patients. Iron is often the best medicine
for their eczema. W'hen restlessness is present, sleep must be secured
with Chloral or Bromides, but morphia is contraindicated. Constipa-
tion must always be relieved, and the best general means of doing this
is by Epsom Salts. Diet must be modified to individual needs; the

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221

ECZEMA

underfed require feeding, the more usual overfed and under-exercised
patient calls for a reducing of diet. Seasoned dishes, salted meats or
excess of salt with food, coffee, and alcohol should all be prohibited.

Fisher^ commends X-ray treatment in eczema, quoting an experi-
ence of 62 cases so treated. A tube of very low penetration, and a
minimum amount of current, are needed, and the duration of the
treatment varies from six minutes in acute cases to fifteen minutes in
chronic, the distance being graduated so that in acute cases the tube
is farther removed from the patient than in chronic.

Hichens,^ impressed by the observation that of twenty-eight cases
of eczema admitted to his children's ward in twelve years, six ended
fatally, supports the view of those who contend that it is dangerous
to cure eczema in children too quickly. In none of the cases recorded
was a post-mortem examination made, so that the exact cause of
death could not be ascertained.

Jamieson* has some pertinent remarks on the incidence and treat-
ment of eczema in infants. Blond and florid cliildren are more subject
to it than brunettes. Of external causes, the most important are the
use of cheap soaps, hard water, and clothing which is too rough, dirty,
or too hot for the season. Of internal causes, defective elimination and
irregular feeding are the most frequent.

As the urine is usually scanty. Pure Water in abundance should be
given. Constipation should be met with Cascara, Grey Powder, or
Phenolphthalein ; where there is much flatulence, JLacto-bacillin is
useful. Small doses of Sodium Bicarbonate are often beneficial.
When the mother nurses the child, her health should be enquired into,
and constipation and anaemia, if present, should be treated.

Stopford Taylor® insists on the advantage of Rest in Bed for
generalized cases ; for localized eruption, the rest provided by masks
and bandages. Crusts are removed by Boric Starch Poultices (boric
acid I part, starch 7 parts). Later, a dusting powder — Dermatol is the
writer’s favourite — may be used in conjunction with poultices. As
the surface gets drier, ointments and pastes may be resorted to. These
should be spread on wet hnt soaked in cold water, and wet butter-
muslin is interposed between the ointment and the skin. The skin
may with advantage be painted over with 2 per cent solution of
Ichthyoi ill water. In the later stage of treatment, the skin may be
anointed with ointment only during the day, and dressings applied at
night. Soaps are usually prohibited in eczema, but they may occasion-
ally be used with advantage : in suppurating eczema of the scalp, for
example, it is recommended that the scalp be rubbed over with equal
parts of Ung. Sulphuris and Sapo Mollis, washed a few minutes after
with Spiritus Saponis Kalinus and then dressed as detailed above with
Sulphur Paste. For very chronic patches, especially with lichenifica-
tion and pruritus, Solid Carbon Dioxide, applied for twenty seconds to
a minute, is very useful. For chronic scaly eczema of the toes and for
indolent ulcers, the author recommends Ung. Resinae B.P., combined
with Sulphur or with Ung. Hydrarg.

ECZEIVIA

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MEDICAL ANNUAL

Kiiosvle^’ has an elaborate study of eczema in association with
occupations, and is sceptical of causations other than external. Of
4142 cases in his experience, fully one-fourth were of determinable
external causation. , The list of occupations concerned includes house-
workers (w'hose cause is chiefly soap), labourers, woodworkers, photo-
graphers, printers, painters, millworkers, bleachers and cleaners,
cloth handlers, tanners, coopers, persons handling drugs and chemicals,
confectioners, bakers, barbers, bar-tenders, handlers of grease, oils and
glues, grocers, plasterers, paperhangers, tobacconists, furriers, workers
ill metals and minerals, dyers, fruit handlers, ice-cream makers,
soap makers, packers, farmers, and florists. In the subsequent
discussion of this paper, the vexed question was debated whether it
was worth while keeping up a distinction between eczema and trau-
matic dermatitis, which are often indistinguishable by clinical or
histological characters. Pusey neatly summed up the argument by
remarking that the distinction is about as essential as that between
natural and artificial ice. The whole debate is well worth reading in
full. {See a/so Skin, General Therapeutics of.)

References. — '^Med. Chron. 1913, Sept, 315 ; liec, 1913, ii, 384 ;

Jour. Child. Vis. 1913, 395 ; ‘^TJier. Gas. 1913, 475 ; ^Med. Press and
Circ. 1912, ii, 402; ^Joitr. Cut. Dis. 1913, ii.

ELEPHANTIASIS. Leonard Rogers, M.D., F.jR.C.P.

F. C. Madden, A. Ibrahim, and A. R. Ferguson^ record their experi-
ence of trials of Lymphangioplasty in elephantiasis, as suggested by
W. Sampson Handley. They have applied the method in eight cases in
Cairo under very favourable circumstances, but with uniformly dis-
appointing results. As long as the patient is kept in the recumbent
position after the operation, the effect is most gratifying, but when he
begins to be up, no matter how long he may have been kept at rest,
the leg becomes just as swollen as before the operation. As Handley
pointed out, the effect of supplying new channels is done away with
by the action of gravity, as no new motive force is supplied. They
also found, both in their cases in men and in experiments in guinea-pigs,
that the artificial lymph-channels do not persist for any length of time,
but the lymphatics in the neighbourhood of the tlireads become
obstructed after a while, on account of the reaction set up by the
tlireads, with the formation of dense and progressively contracting
fibrous tissue. Eventually the thread is penetrated by cells and
converted into an impervious band of scar tissue.

Reference. — '^Brit. Med. Jour. 1912, ii, 1212.

EMPYEMA. /. /. Perkins, M.B., F.R.C.P.

After a study of i5.j. cases, Holt^ reiterates the great value of the
Siphon treatment of empyema in infants and young children. The
cause of death in acute empyema in children under three, at which
period the mortality is very high, lies not in the advent of^complications
but in the disease itself, which therefore requires better management.
Of the deaths from empyema in infants. So per cent are due to exhaus-

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223

EMPYEMA

tioii from the long suppuration and general sepsis. For about a week
after opex'ation the children frequently do well, then the temperature
rises and shows wider fluctuation, though the discharge is free, wiiile
expansion of the lung is imperfect. Then follows progressive weakness
and asthenia. The 154 cases (all under 3 years of age) cover a period
of seven years of hospital work, during which various modes of treat-
ment were employed. For the first period of about three years,
practically all cases were treated by simple incision and drainage ;
for the next period of about two 3'ears, the routine treatment was rib
resection ; for the past two and a half years nearly every case has been
treated with siphon drainage. The advantages of siphon drainage
are best shown if cases in patients under nine months of age only are
considered : Rib resection, all cases fatal ; simple incision, 8 cases,
I recovery ; siphon drainage, 8 cases, 3 recoveries. The method
adopted is a modification of that introduced by Bulau, the founder of
the treatment. A puncture incision is made with a small scalpel, the
dimensions of the wound being slightly smaller than the drainage tube
to be used. The tube should be firm and of large calibre, corresponding
to a No. 27 Fi'ench catheter. A collar is fixed round the tube to prevent
it slipping into the cavity of the chest, and just above the collar a
piece of broad tape is fitted, which is applied to the chest wad and held
in place by adhesive plaster in such a manner as to close the opening
into the chest and make it airtight. After introduction, the distal end
of the tube is clamped with artery forceps until complete connections
are made, the drainiage tube being then joined to a longer tube which
I'uns to an ordinary wash-bottle standing on the floor hy the cot. This
bottle contains about half a pint of sterile normal saline solution,
beneath the surface of which the rubber tube opens. Continuous
drainage thus takes place from the chest into the bottle without the
admission of air into the pleural ca\dty. The average tune of wearing
the tube Avas 16 days, the longest time being 35 days, and the shortest
3 days. The advantages of the method are that it avoids all disturbance
to the cliild by daily dressing, and especially that it promotes the
expansion of the lungs by preventing free admission of air to the pleural
cavity. Biilau’s aim in introducing siphon drainage was to set up a
negative pressure within the pleural cavity, and so to overcome the
natui'a! elasticity of the lung which is the main factor in the prevention
of its expansion.

Reference. — ^Amer, Med. 1913. 381.

Priestley Leech, M.D., F.R.C.S.

Chandler^ reports a case of empyema in a child five weeks old, who
recovered after operation. The organism found was Staphylococcus
pyogenes aureus. The child had an open branchial cleft just above
the right clavicle which discharged pus, and tliis contained the same
organism. Turner Thomas^ has made a study of tiiis condition in a
body hardened in formalin, the seat of a right-sided empyema which
had not been opened during life. From this case he draws inferences

224

MEDICAL ANNUAL

which are rather at variance with some of the accepted views. The
massive parietal type of empyema usually extends to the bottom of the
normal pleural cavity, and is not general, but is completely walled off
above from the rest of the pleural cavity by adhesions ; this explains
the slight mobility of the dullness on percussion on changing the position
of the patient, as well as the fact that the upper level of the dullness
is not a straight line, as it should be if the fluid was free to seek its own
level. Skoda’s resonance may not be due to relaxation of the lung
above the pus, but to the fact that the functionating portion of the
lung is doing compensatory w^ork. *

The most important factor in preventing obliteration of the empye-
matous cavity and closure of the sinus is the pressure of the air admitted
through the drainage opening into the empyematous portion of the
pleural cavity, where it neutralizes the expanding effect of the air
coming through the trachea. Murphy overcomes this by aspirating
the pus and injecting a formalin-glycerin solution, but his method has
not yet received general approval. The ideal drainage method is that
based upon the suction or syphon principle, but the apparatus in use
allow air to leak round the tube. An opening through the eleventh
rib or interspace of a given size will drain more perfectly than one at
the usual level, and will better prevent the entrance of air, since the
pus will be constantly escaping and tending to fill the space in and
around the tube. He treated five cases of massive empyema by this
method of dependent drainage, and the time of cure was less than the
average.

References. — “^Lancet, 1912, ii, 1776 ; ^Amer. Jour. Med. Sci. 1913, i, 405,

ENDO-BRONCHIAL TREATMENT. TF. G. Porter, M.B., F.R.C,S.

Heilskof and Mahler^ have treated 27 cases of asthma by direct
applications to the bronchi. All their patients had had previous
medical treatment. The bronchoscope is passed in the sitting position,
and the patient is \varned to breathe quietly and not to cough.
Briinings’ spray is passed dowo. to the bifurcation, and a 3 per cent
Cocaine Solution containing Adrenalin is injected into each bronchus.
From eight to ten injections were made in each case. Of 3 cases of
chronic bronchitis treated in this way, improvement was noted in 2,
while I was not affected. Of the 27 cases of asthma, 5 were cured,
10 were improved, and 12 were not affected. Sobernheim^ has adopted
the same treatment, but uses a J per cent solution of cocaine with
adrenalin; of 12 cases, marked improvement has been noted in 10.
He quotes Ephraim, who out of 58 severe cases obtained a cure in
37 and improvement in 14, while only 7 were unaffected.

References. — ^Monat. /. Ohr. 1913, 1O7 ; ^Berl. Min. Woch. 1913, 1359.

ENDOCARDITIS, ULCBRATIYE. Carey Coombs, M.D., M.R.C.P.

Of late, bacteriological and clinical reseaich has defined for us the
existence of a group of cases of endocardial ulceration possessing very
definite symptomatic features, and apparently due in every case to
a streptococcus of a certain type. Of course, endocardial ulcei'ation

NEW TREATMENT

225

ENDOCARDITIS

may be produced by the ravages of almost any micro-organism ; for
instance, Dean^ records an example of generalized actinomycotic
infection in which the endocardium was implicated. It is not, however,
with such rare cases that we are now concerned, but with a group to
which various names have been given — chronic ulcerative, infective,
or septic endocarditis, endocarditis lenta, and so forth. Horder,^
Libman,^ Schottmiiller,^ Rosenow,^ Major,® Jochmann,” Lewinski,®
Schone,® Lorey^^ and others, have called attention to the close associa-
tion of this type of the disease, the clinical features of which are
described below, with streptococci. This association is not, however,
invariable : among Libman's and Hordei's cases were several in
which blood cultures yielded B, influensis ; and Major mentions one
from which the pneumococcus was grown, and another associated
with d/. zymogenes. For all practical purposes, however, it may be
said that recent work has defined a form of slowly progressive
ulceration of the endocardium due to streptococci.

The classification of this streptococcus is a difficult matter. Most
agree that its characteristics are fairly constant. Libman contents
himself with calling it the endocarditis coccus; Schottmiiller calls it
Strepiococcus viridans; Rosenow belives it to be a modified pneumo-
coccus ; while Horder and others insist on its close similarity to the
saprophytic cocci of the alimentary tract. In connection with the
latter fact, it is important to note that oral sepsis is regarded by Joch-
mann and others as providing a possible port of entry for the infective
agent.

Among the various interesting side-issues of this bacteriological
problem is one of some practical importance : What is the relation of
this streptococcus to that of rheumatic infection ? Poynton and
Paine^^ have very ably set forth their reasons for believing that there
is a directly and purely rheumatic form of malignant endocarditis : a
history of acute rheumatism is the rule, especially in the type of
ulcerative endocarditis under discussion ; the micrococci recovered
from the latter are at least very like those associated with acute
rheumatism ; experimental inoculations with these cocci produce a
simple type of endocarditis in some animals and a malignant type in
others ; and finalh% it is hard to draw a line between rheumatism and
malignant endocarditis from the clinical viewpoint. The present
writer, however, 12 failed to find histological proof of rheumatic infection
even in the most “ rheumatic cases of malignant endocarditis ;
though Palfrey and Ayer^® describe a case of endocardial ulceration with
myocardial lesions, some of which were like those of rheumatism. The
whole question is part of the larger one, as yet unanswered, of what
constitutes identity on the one hand or diversity on the other among
the streptococci.

Apart from the frequent history of rheumatic fever, the most
important among the predisposing causes of endocarditis lenta is the
patient’s age, which lies usually betv^een twenty and forty.

Pathology. — Libman thus describes the lesions : '' When the

ENDOCARDITIS

MEDICAL ANNUAL

zzG

mitral vah'e is involved, as it is in the larger number of cases, there is
a tendency for the vegetations to spread up on the left posterior wall
of the auricle more than on the valve itself. Often the chordae tendineae
attached to the posterior flap are covered to a greater or lesser extent
b}" vegetations. Nearly always the anterior flap is also involved, and
here the vegetations tend to grow down over the chordae tendineae, the
involvement of the latter being often extensive. Not uncommonly
the chordae are ruptured, the torn ends at times being massed together
by vegetations at the edge of the flap, or the lower ends may be found
lying loose near the papillary muscles. The vegetations are yellowish,
greenish, pinkish, or reddish in colour, and vary much in size in different
cases. As they grow older they become firmer and assume a more
greyish colour. When the aortic valves are involved, there may be
only a small vegetation on one or more of the flaps of the valve.
On the other hand, there may be enormous green masses that must
block the orifice to a greater or lesser extent. The vegetations have
a tendency to extend down over the endocardium at the position of
the septum membranaceum and over the ventricular aspect of the
aortic flap of the mitral valve and dowm over the chordae tendineae.
At times they have a stalactite-like appearance. There may develop
an aneurysm of the aortic flap of the mitral valve. Ulceration of
the aortic valve at times occxirs ; ulceration of the mitral flaps is
rare.”

In thirty-four cases he found the auricular endocardium attacked
twenty-five times, the mitral flap twenty-eight times, the chordae
twenty-seven times, and the aortic cusps nine times only. One fact
of particular importance is a tendency to healing on the part of these
lesions : a possibility also alluded to by Amsler^'^ and Maixner.i^

Baehi^’^ has examined the kidneys from cases of chronic ulcerative
endocarditis : he finds certain glomerular changes associated with
the streptococcal cases, but not with those due to other organisms.
These changes consist of a gradual necrosis of part or the whole of the
Malpighian tuft, proliferation and subsequent necrosis of the epithelium
of Bowman’s capsule, and gradual replacement of the necrotic mass
by Jiewly organized connective tissue. Cocci were found in these
lesions.

Symptoms. — The clinical picture presents cei'tain definite peculiarities.
The onset is very insidious ; progressive weakness is often noticed
first. Fever is moderate, and may even be continuously absent for
weeks. Rigors and excessive sweating are exceptional. Articular
pains, with or without slight swelling of joints, are the rule ; Libman
finds tenderness over the lower sternum a common symptom, and
ascribes it to abnormal regenerative activity of the marrow. Painful
nodules under the skin, like small patches of erythema nodosum, are
often noted, and particularly on the fingers (Osier). Petechiae and
ictinal hcemorrhages are common. The complexion is pale, a brownish
pigmentation developing later on the face and even over the trunk
(Libman). The blood shows a progressive fall in red corpuscles and

KEW TREATMENT

227

ENDOCARDITIS

haemoglobin ; leucocytosis may occur, but it is not constant. ’Weak-
ness and wasting are usually conspicuous. The physical signs of
valvular disease are usually, but not invariably, discovered. The
spleen is generally enlarged, sometimes in a conspicuous degree. There
are often evidences of a hsemorrhagic nephjritis.

In any case where a suspicion of chronic ulcerative endocarditis is
entertained, the only sure way of diagnosis lies in blood cultivation.
The technique of this procedure was described in the Medical Annual
for 1911, and need not be repeated here. The identification of the
streptococcus, if this be the organism found, is not an easy matter, and
should be entrusted to a bacteriologist with special knowledge of
the matter.

Prognosis. — While the general outlook is gloomy, it is legitimate
to take note of the very substantial evidence adduced by Libman and
others in favour of the possibility of cure in cases of chronic ulcerative
endocarditis. Libman says that in such cases the patients may
eventually die of uraemia ; they may display evidences of valvular
disease with very little sign of active infection, the final upshot of
such cases being as yet unknown ; they may die of broken compensa-
tion. In patients w’hose infective process is dying out, he says the
fever is less marked and there are longer afebrile periods, the painful
nodules are much less likely to appear, and petechiae and renal haemor-
rhage are far less abundant ; but the spleen remains large, and
arthralgias and sternal tenderness are no less pronounced.

Treatment. — A few cases of recovery are on record, but since it is
possible that cure may be effected by natural means, too much
importance must not be attached to the methods used. For example,
Jochmann had two recoveries out of seven cases ; three of his patients
were treated with autogenous Yaccines and Sera, but two died. One
of the recoveries was therefore associated with this treatment, while
one was not.

Hemsted'^' records an extremch^ interesting case, that of a young
woman with a congenital cardiac defect, whose endocardium became
infected with a streptococcus of the type alluded to above. The
symptoms were alleviated by a vaccine made from organisms grown
from the circulating blood, but this did not effect a cure. A serum
was, however, prepared from a horse inoculated with the patient’s
organism, and injection — with later oral administration — of this was
followed by an apparently complete cure. Vaccines were given in
conjunction with the sera. It is advisable to give a trial to these
methods wherever possible. In one of Lorey’s cases, an unusually
acute one for this t^^pe of streptococcus, recovery occurred ; improve-
ment began shortly after a single *6 c.c. dose of Salvarsan given
intravenously.

[Attention to all possible paits of entry is absolutely essential : it
is especially necessary to eradicate oral sepsis as far as possible. — C. C.]

References. — Med. Jour. 1912, ii, 1303 ; ^Quart. Jour. Med. 1908,
ii, 2S9 ; ^Amer, Jour. Med. Sci. 1912, ii, -313 ; ‘'^MiincJi. nled. Woch. 1910,

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MEDICAL ANNUAL

SSo ; '\Joitr. Med, Vis, igog. vi. 425 ; ^ Johns Hop. Hosp. Bull. 1912, 326 ;

Mill. Woch. igiz, 436; Hbid. 1913, 443.* ^Deut. med. Woch. 1912,
579; ^^Jour. Anwr. Med. Assoc. 1912. i, 1S24 ; ^^Ouart. Jour. Med. 1912,
July, 463;^ ^'Hancet 1912, i, 1529; ^^Bost. Med" and Surg. Jour. 1912,
ii. 55 J '^^Corves.-Bl. f. Schw. Aevzte, 1912, Apr. 10 (Brit. Med. Jour. Epit.
1912. li, 25); ^'^Wicn. Min. Woch. 1912, 1265; ^^Amer. Jour. Med. Sci,
igi2, ii 327 ; ^'^Lancet, 1913, i 10,

ENURESIS. Frederick Langmead, M.D., F.R.C.P.

Diagnosis. — J. W. Simpson^ points out that although there are
a number of congenital malformations which may cause enuresis,
only two of these are likely to lead to mistakes in diagnosis — epispadias
in a female, and a congenital deficiency between the bladder and
vagina. If there are no such defects, the mental state of the patient
may be at fault. Although a definite case of idiocy would not fail
to be recognized, “ backwardness ” might be overlooked. Enuresis
associated with pain during micturition may be due to well-marked
hyperacidity of the urine, but other possibilities should not be lost
sight of, such as stone in the bladder, phimosis with balanitis, a narrow
meatus frequently with a small ulcer at its margin, or rarely tubercu-
losis of the bladder. New growths of the bladder and acute cystitis
also cause painful micturition, but other more noticeable symptoms
and signs at once differentiate these from simple cases of incontinence.
If stone be present, the enuresis usually occurs during the day when
exercise is being taken, pain is felt apart from micturition, and a small
amount of pus is nearly always present in the urine. A bimanual
examination, with one finger in the rectum, will probably discover a
stone if present. Certain conditions, by causing reflex irritation,
may prolong the duration of incontinence. Thus phimosis, vulvitis,
thread-worms, and anal fissure may be named as contributory causes,
but the curing of these conditions does not of itself remove the incon-
tinence. Only rarely, except in the case of removal of adenoids, will
attention to subsidiary causes accomplish this.

Treatment. — For cases of simple incontinence, Simpson has often
found change of air and scene very beneficial. As incontinence
often occurs during the first two or three hours of sleep, the child must
pass water immediately before going to bed. Two hours afterwards
the child should be roused from sleep and the bladder emptied again.
This is especially indicated if the urine is alkaline. It is also important
to establish regular habits of urination during the day, and the child
should be encouraged to retain the urine as long as possible, even at
the risk of some discomfort. The amount of fluid taken during the
day should not be restricted, but the last meal and fluid should be
taken at least one hour before going to bed. Tea and coffee should
never be given. He has not found tilting the foot of the bed, or the
usual methods of preventing the child from lying on its back, of definite
value. Plenty of fresh air, and a fair amount of exercise, he considers
important factors in effecting a cure.

He places reliance chiefly on three drugs, Belladonna, Citrate of
Potash, and Ur 0 tropin. To use them intelligently it is necessary, in his

NEW TREATMENT

229

EPILEPSY

opinion, to examine the urine carefull3^ If this is normal, the treatment
consists in giwng a tonic medicine, and afterwards belladonna. He
begins with 10 min. of the tincture two or three times daily, and
gradually increases it to 20 or 25 min. Sometimes the urine is
extremely acid, loaded with urates, of high specific gravity, and
diminished in quantity. Under these circumstances one must first
reduce the acidity of the urine by using citrate of potash in doses of
10 gr. thrice daily, or larger doses if necessary. When the acidity has
been reduced, the belladonna should be begun. Meat is contra-
indicated. Sometimes the urine is neutral or alkaline, of low specific
gravity, and contains triple phosphates, with perhaps a few pus cells
and a trace of albumin. In these cases dieting is of first importance,
carbohydrate food, as far as possible, being prohibited. If the urine
is veiy^ alkaline, Acid Sodium Phosphate may be given ; when the
alkalinity has been reduced, belladonna should be used. If the urine
contains B. coli communis, it is wise at first to reduce the acidity by
administering citrate of potash ; and then uro tropin, 5 or 10 gr. thrice
daily, often proves of immediate benefit. If there is a mixed infection,
Salol is often useful, or a Yaccine may be employed with advantage.

He has rarel}^ seen good results from Antipyrin or Suprarenal
Extract, but advocates trying Ergot if belladonna fails, and Thyroid
Extract if the child is mentally backward.

If the child is highly nervous and suffers from disturbed sleep or
night-terrors, the addition of 5 or 10 gr. of Potassium Bromide to the
last dose of belladonna at night often does good.

Epidural Injections and Lumbar Puncture he considers too drastic
except in very extreme cases.

Reference. — '^Edin. Med. Jour. 1913, i, 49.

EPILEPSY. {See also Brain, Surgerv of.)

Purees Stewart, M.D., F.R.C.P.

Treatment. — The advantages of a Chloride-free Diet in epileps}^
are now so well recognized that it is unnecessary to discuss the regime
in detail. Suffice it to state that the withdrawal of chlorides appears
to render the organism more sensitive to bromides, so that a smaller
dose of bromide is efficient in controlling the epileptic fits, ^"iteman,
in his thesis of igo6, records the results of examination of the cerebro-
spinal fluid in a series of epileptics. He found a slight excess of
chlorides, amounting to 7 or y-J grams per Itee, instead of the normal
6 grams. A chloride-free diet, in addition to diminishing the fre-
quency and intensit}?' of the fits, produces a corresponding diminution
in the chloride content of the cerebrospinal fluid. Conversely, Sicard
and Javal have showni that excess of chlorides in the diet of epilep-
tics produces an increase of chlorides in the cerebrospinal fluid.

Netter^ maintains that Calcium Salts have a special sedative action
on the cerebral cortex, being antagonistic in this respect to sodium
salts, which are stimulant. He therefore urges the administration
of calcium salts in addition to a chloride-free diet

EPiLEPSY

230

MEDICAL ANNUAL

Surgical Treatment. --This has been undertaken from time to
time by numerous observers, such as Alexander, of Liverpool Medical
Annual, 1913), and others. Recently Tilmann,^ of Cologne, has dis-
cussed the indications for surgical intervention in idiopathic epilepsy.
At the outset he strikes out, as unsuitable, all cases of neuropathic
heredity, with a family history of mental disease, epilepsy, or alcoholism ;
also cases of hysteria and hystero-epilepsy, together with syphilitic or
alcoholic patients. Further, he excludes the epileptiform attacks of
urasiinia, malaria, and other toxic or infective diseases. The cases
where surgical intervention is worth considering are those in which a
previously healthy patient, without neuropathic heredit^^ suddenly or
gradually becomes epileptic, often after some trauma. Depressed
h'actures of the skull call for prompt operation. Even apart from this,
injuries to the skull can induce epileptic fits in previously healthy
individuals. Thus a hospital nurse fell and struck her head on the
stone floor of an operating-theatre. Without any signs of local trauma
a series of sixteen severe epileptic fits followed. Lumbar Puncture
withdrew 30 c.c. of blood-stained fluid. The fits ceased at once, and
up to the time of publication, now’ three 3^ears ago, have not recurred.
As regards Trephining for traumatic epilepsy, the best results are
obtained by early operation. In some cases, by careful observation, we
can detect evidence of a focal lesion, whether in the form of a localized
scar or depression, or local paralytic or irritative phenomena, which
serve to indicate the spot for trephining. Jacksonian fits are of great
diagnostic value, but only in cases w^here the trauma has occurred in
the region of the central fissure. But even in generalized fits following
head injuries, Tilmann claims to have obtained occasional successful
results. In two such cases he found evidence of a local trauma in
childhood, although the fits did not appear till six or ten years later.
Nevertheless, careful examination of the cranium show^ed local tender-
ness at the site of the injury in one instance and a scar in another.
Trephining revealed subjacent chronic periosteal thickening, and the
fits wei"e permanently cured. Even in non -traumatic idiopathic
epilepsy Tilmann has frequently trephined. He states that in about
50 per cent of cases the dural tension is above the normal, and that, in
such cases, on incising the dura the arachnoid is oedematous and
swollen, and the subjacent veins of the pia dilated and varicose. Out
of 52 cases operated on by Tilmann, 2 died, one from shock, another
from pneumonia. Of the remaining 50 cases, 30 remained free from
fits for four months and upw^ards, and 8 of these had been free for
over. three years. In 3 cases the fits continued, though less severely,
whilst in 10 no improvement followed, and in 2 of them the disease
was aggravated. Radiographic examination of the skull occasionally
affords valuable indications.

Retuiming to medicinal treatment, it is worthy of note that in a
certain number of epileptics, as indicated by Claude and Schmiergeld,®
there is evidence of thyroid deficiency. Such patients are remarkably
benefited by Thyroid medication, either in association with bromides,

NEW TREATMENT

23 ^

ERYTHEWA AB IGNE

as indicated by Claude, or independently of bromide treatment as in
tvvo cases recorded by Gelma.*^

Lastly, it is of interest to record further observations on the Grotalin
treatment of epilepsy, originally introduced by Spangler, of Phila-
delphia, with which readers of the Medical Annual are already familiar.
In more recent publications Spangler amplifies his favourable results,
based on the observation of 148 cases in three and a half years. The
mode of preparation of the crotalin is as follows : The fresh snake-
venom is obtained by causing the snake to bite on the edge of a glass
funnel, the venom running into a bottle beneath. The venom is
spread on glass and allowed to dry, forming a yellow substance which,
when broken up, forms scales of somewhat crystalline aspect. In
this dried state it keeps indefinitely without deterioration. When
required for use it is dissolved in sterile water and glycerin, to which
are added a few drops of trikresol as an antiseptic. This sterile anti-
septic solution is then sealed up in glass ampoules containing from
ih) '^'0 12V of the dried venom. The strength of dose varies with
different individuals, and it is prudent to begin with ujo injected
intramuscularly, ever}^ five or seven days, gradually increasing to
'oil gr- or more, according to the technique already described {see
Medical Annual, 1913, p. 230).

The foregoing treatment being frankly empirical, Spangler has
endeavoured to find a rational explanation of the beneficial results so
obtained. He offers an explanation in the fact that crotalin contains
at least two active principles, of which one, a peptone, has a paralyzing
effect on nerve-tissue, whilst the other, a globulin, acts on the blood,
diminishing or destroying its coagulability. He points to the increased
coagulability of the blood which sometimes, for twenty-four or fort>"-
eight hours, immediately precedes an epileptic fit, and quotes in support
of this thesis John Turner and Aldren Turner. Woodruff, of Roches-
ter (New York), also supports Spangler’s views ; but the value of his
evidence is somewhat diminished by the fact that he claims crotalin
as a cure, not only for epilepsy, but also for asthma, neuralgia, neuritis,
lumbago, sciatica, coccygod^mia, tics, chorea, functional aphasia,
pleuris3L and phthisis. All this is too good to be true.

References. — ^Soc. Med. d. Hop. 1907, Mar. S ; ^Mi’mch. med. Woch. 1912,
26S3 ; ^L’Encephaht 1909, Jan. i ; ^Rev. de Med. 1913, 26.

ERYSIPELAS. E. Graham Little, ilf.D., F.R.C,P,

Arnold^ adopts and recommends a “ country remedy ” for erysipelas
in the internal and external administration of Buttermilk. Dressings
soaked in this fluid are applied freely to the inflamed surface and kept
continually wet, and the patient is encouraged to drink it as well.

Reference. — '^Pract. 1913, i, 900.

ERYTHEMA AB IGNE. E, Graham Little, M.D., F.R.C.P.

HartzelT remarks on the infrequency of this condition in America,
and the scanty reference to it in text-books, and records some cases
of interest, notably one in which the curious mottling characteristic

ERYTHEMA AB IGNE

232

MEDICAL ANNUAL

of the disease was produced by application of a hot-water bottle on
the lumbar region. The author regards general ill-health as a con-
tributing cause. Histological examination of the pigmented and
erythematous stages of the disease showed clearly that the affection
is inflammatory, and not simply a staining of the skin by blood pigment.

Directions as to Treatment may be summed up in the caution to
Avoid Local Heat, especially that of an open fire ; in early stages
Cooling Lotions and Pastes may be applied with advantage.

Reference. — ^Jonr. Cut. Dis. 1912, ii, 461.

ERYTHEMA COMPLICATING INFECTIOUS DISEASES.

E. W. Goodall, M.D.

Weill and Gardere^ have published an account of several cases of
secondary erythema occurring during or soon after an attack of measles.
They discuss at length the diagnosis and patholog}^ without arriving
at any very definite conclusion on the latter point, except that usually
these rashes are to be taken as evidence of some secondary infection,
especially by streptococci, and that they are due to an intoxication and
not to an invasion of the blood hy micro-organisms. They dismiss
the hypothesis that the rashes and the other symptoms which may also
be present are due to hepatic, renal, or adrenal insufficiency, on the
ground that these conditions are by no means constantly present.
Some account was given of these erythemata in last year’s Annual.

Reference. — '^Rev. de M&d. 1913, 549-

ERYTHEMA NODOSUM. E, Graham Little, M.D., F.R.C.P.

Gosse^ has investigated anew the supposed relation between erythema
nodosum and rheumatism, concluding that the evidence for any causal
connection between these affections is extremely scanty. He bases
his arguments on the careful study of 100 cases of erythema nodosum
occurring at St, Mary’s Hospital in the last 12 years. He also rejects
the now more prevalent view that erythema nodosum is a form of
erythema multiforme, and regards the disease, with Trousseau, Lendon,
and others, as sui generis, an “ infective disease of separate entity.”
In one set of these cases in his series there was apparent infectivity,
the incubation period being a fortnight, and he claims that this observa-
tion is not of rare occurrence. But no specific germ has yet been
discovered.

Tonsillitis was the most frequent association with erythema nodosum
in the hundred cases analyzed. A systolic murmur at the apex and
pains in the joints come next in frequency ; the heart symptoms
usually disappear within two or three weeks. The rash may be ushered
in by shivering, rigor, headache, vomiting, and anorexia ; in severe
cases by pain in the back and joints and effusion in the latter. Pyrexia
may precede the eruption, and usually persists for some days, the
temperature becoming normal within a week. There was not a single
instance in the hundred cases of a repeated attack in the same person.
Salicylates, even when pushed to heroic doses, were quite without
effect either on the pyrexia or on the symptoms. There is no specific

NEW TREATMENT

233

EYE, THERAPEUTICS OF

treatment, and beyond ensuring Rest in Bed little need be done.
The convalescence is often prolonged on account of the severe ansemia
wliich is a frequent sequel.

An interesting pendant to this paper is found in a contribution by
Meara and Goodridge,^ who espouse the view that tuberculosis may be
one of the causes, which are multiple, of erythema nodosum. The
throat is the portal of entry for the infection in many instances. The
authors describe in detail a remarkable case of erythema multiforme
and erythema nodosum together, occurring in a young woman,
apparently as an early manifestation of tuberculosis terminating in
death from meningitis.

References. — ^Pract. 1913, ii, 240; -Amer. Jour. Med. Sci. 1912, i, 393.
ERYTHRiEMIA. (See Polycythjemia.)

EYE, GENERAL THERAPEUTICS OF. A. Hugh Thompson, M.D.

Hydrogen Peroxide. — As a non-toxic antiseptic this is strongly to be
recommended as an alternative to other drugs in conjunctival, corneal,
and post-operative inflammations. Its most serious drawback, says
Harr}',^ is the danger of using it vnth any of the silver salts. Another
very slight disadvantage is that the frothing produced may be a source
of alarm to patients. The strength recommended is that of the B.P.
solution, namely 3 per cent.

P. Knapp- recommends 2 or 3 per cent of Resorcin in a saturated
solution of boracic acid for cases of chronic conjunctivitis, especially
when zinc sulphate causes irritation.

Carbon-dioxide Snow (see also Medical Annual, 1913, 236) has been
proved inferior to the old remedies in the treatment for trachoma at
Vienna, in Prof. Fuchs’ clinic. “ It w’as found,” says Ernest Thomson,®
” when carbon-dioxide snow and copper sulphate were employed one
against the other in the right and left eyes of the same patient, that there
was distinctly more scarring with the snow than -with the copper.”
As time went on, this became such a convincing fact that the snow was
given up.

Darier, of Paris, emplo^^s Radium in rodent ulcer and epithelioma of
the eyelids, in spring catarrh, and in chalazion. ” In the last-named
affection he finds that a couple of applications, each of twenty minutes’
duration, made at intervals of a fortnight, suffice to cure many cases
without recourse to operation.”

Diaphoresis is a time-honoured method of treatment, but wliile it
has always been largely employed by a few ophthalmic surgeons, and
occasionally b}' many, in such diseases as sympathetic ophthalmia, the
cumbersome apparatus required for vapour baths, and the depressing
effects that frequently follow pilocarpine injections, have tended very
much to limit its employment. In the external application of guaiacol,
we have a method which escapes both these drawbacks. In advocating
this, Russ Wood and F. A. Anderson® point out that its object is to
procure the absorption of toxins by the blood, not directly, for it is
doubtful if any toxic substances are got rid of by the skin, but indirectly;

EYE, THERAPEUTICS OF

234

MEDICAL ANNUAL

for as a necessary result of excretion of water by the sweat-glands, the
blood is made tliicker, and absorbs more fluid from the body tissues.
The toxins are absorbed along with the fluid, and are excreted by the
natural channels. The method of application is as follows ; The
patient is given an aperient over night, and a very hot bath in the
morning, after which he is put to bed between blankets with hot-
water bottles. “ The guaiacol pigment, which consists of equal parts
of guaiacol and olive oil, is now applied, two drachms of this mixture
constituting the average dose. This amount is poured on a piece of
lint six inches square, and is then smeared — not rubbed — over an area
of the epigastrium about the size of the lint. The piece of lint is now
applied over the area so treated, and the whole covered with oiled silk,
which is fixed in its place by strapping, and left in position for about
four hours. A glass of hot lemonade or peppermint water may be
given at the commencement.’' The authors have used this treatment
for retrobullar neuritis, papillcedema, vitreous opacities, chronic irido-
cyclitis (especially if of traumatic origin), non-ulcer ative keratitis, and
the various ocular manifestations of syphilis.

Favourable accounts of Hetol, in the treatment of tuherculous iritis
have from time to time appeared in Germany. Pfiuger, Wickerkiewitz,
and others, have used it in the form of subconjunctival injections.
Cohn, of Mannheim, ® finds that in the form of a solution of 2 to 5 per
cent simply dropped into the conjunctival sac, it is equally effective.

H. P. Bennett, of Newcastle,’ reports a remarkable case of retinitis
proliferans wdth retinal haemorrhages in a young woman of twenty-three,
in which mercury, potassium iodide, iron, and calcium lactate had all
been tried without success, but which yielded to Thyroid Extract, so
that the vision, \vhich had been right left improved in seven
months to right {[ partly, left For four months she took i gr.
of thyroid extract thrice daily, and for a further two months i gr.
once daily.

Iiocal Anaesthesia for Enucleation of the Eyeball. — This is the usual
routine procedure in the clinic of Professor Siegrist at Berne. The
procedure employed is described by Ernest Thomson,® who testifies
that in the three operations that he saw, neither patient gave any
evidence of pain. The conjunctival sac is cocainized in the ordinary
way, and a i or 2 per cent solution of novocain, to which, after steriliza-
tion, a few drops of adrenalin (i-iooo) have been added, is used to
produce ansesthesia of the deeper parts. About 5 c.c. of this solution
are injected by means of a long specially-curved needle, 2 c.c. on the
temporal side, 2 c.c. on the nasal side, deeply behind the eyeball, and
an additional i c.c. in the neighbourhood of the muscles. The stronger
solution is suitable for young and robust patients, the weaker for the
old and decrepit. A sedative is given (0*5 gram veronal) the night
before, and also half an hour before operation.

References. — '^Prescriher, 1913, igS ; -Ibid. 208 ; ^Ophthalmoscope , 1912,
379 ; ^Ibid. 339 ; ^Ihid. 347 ; ^^Miinch. med. Woch. 1913, 979 ; ’^Ophthalmo-
scope, 1913, 20 ; ^Ihid. 1912, 149.

NEW TREATMENT

235

F>ECES, EXAMINATION OF

F^CES, EXAMINATION OF. {See also iVMCEBiASis ; Cancer,

Laboratory Diagnosis of ; Pancreas, Functional Efficiency
OF.) O. C. Gntner, M,D.

The clinical examination of faecal matter is laid stress on by Goiffon,^
who points out that no deductions can be made from a laboratory
study of the material unless it represents the relics of a special diet.
The volume, colour, consistence, aeration, odour, and microscopic
examination are investigated. A portion is teased out with water

The diagram shows
in which part of the
intestine the different
forms of digestion
are specially active.
The starch disappears
in the ascending colon
in proportion as the
iodophile bacteria and
yeasts disappear.

(Ajfer Gifi^on.)

Siaich

Fat

i\!uscie-iihc

Celtuiose

Connective tissue.

iS. — Rkj’Resentixg tiik Aciivirv ok Dioestiox i\ the Intestine.

and ground up in a mortar. Normally, the supernatant fluid should
be free from particles, while the deposit shows a few deformed muscles,
fibre cells, starch granules, soaps, and undigested vegetable debris as
the only constituents. The signs of insufficient digestion are abundance
of muscle fibres, bacteria stainable with iodine, leucocytes, red cells,
crystals of oxalates, and ammonio-magnesium phosphate. An acid
reaction points to fermentation of hydrocarbons, while an unduly
alkaline reaction means proteolytic putrefaction.

F>€CES, EXAMINATION OF

236

MEDICAL annual

The following indicate the presence of ulceration : the occurrence
of a precipitate, leaving a clear fluid, on adding saturated mercuric
chloride (test for albumin), the presence of blood, and of pus cells in
large number. The faecal characters of certain intestinal disorders
are given as follows. False diarrhoea, .more or less fluid consistence,
brown colour, alkaline reaction, putrid odour ; no food relics. Intes-
tinal irritation : mucus, liquid full of nucleo-proteid, easily putrescible.
Colitis of ascending colon : watery, nucleoproteid or mucus present.

I'he large black organisms
represent the iodophile flora.
The varying content in
microbes is indicated by the
relative density of those
drawn. The great abund-
ance of organisms in the
caecum (where digestion of
cellulose is so vigorous,

1 8) is shown by the close
5LgS>’egation of lines. It is
here that formation of gas
and volatile /atty acids takes
place.^ It is in the same
situation that the iodophile
bacteria are so prominent.
The digestion of cellulose of
potato liberates the starch
grains, \vhich are dealt ^with
by certain microbes. These
take up the starch and accord-
ingly become stainable with
iodine. It is in the caecum
that the biliary pigments are
cuiuerted into stercobilin, in
virtue of the reductive pro-
cesses going on there.

{After Goiffon.)

/* ig . 19. — Distributio.n of Microues ix the Intes'iinh.

insufficient digestion of food. Colitis of descending colon : very
liquid, with abnormal putrefaction. Intestinal fermentative d^^spepsia ;
excessive fennentation of hydrocarbons : very acid reaction, abundant
gas, richness of iodophile flora. Pancreatic achylia : abundant,
watery, alkaline faeces, with neutral fat, muscular fibres, no amylase.
{See also Figs. 18, 19.)

Ova . — A good method, devised by Yavita, is strongly recommended
by \Volfl.“ Five different pea-sized parts of the faeces (taken as fresh

NEW TREATMENT

237

FIBROSITIS

as possible) are placed in a test-tube with. 25 per cent antiformin (pure
antiformin would destro3J- the ova) and an equal volume of ether.
Agitation causes the faecal matter to dissolve, with rapid evolution of
gas. Filter through a hair-sieve, centrifuge the filtrate for a minute,
and examine the deposit.

References. — ^Presse MM. 1913, 645; -Berl. klin. Woch. 1913., 301,
FAYUS, {See Ringworm.)

FIBROSITIS. Hefhevt Ffench, M.D., F.R.C.P,

A. P. Luff, ^ in his Harveian Lecture, discusses this subject in so
informing a manner that we have ventured to quote from it at some
length. He sa^^s, “ In the great majority of the cases of so-called
chronic rheumatism, the pathological change is in the white fibrous
tissue in various parts of the body, and to this condition the term
‘ fibrositis ’ has been very aptl^’ applied. The essential pathological
change is an inflammatory h^^perplasia of the white fibrous tissue in
various parts of the bod}^ associated wdth exudation and proliferation
of the connective- tissue elements, leading to swelling and thickening
of the affected fibrous tissues. This condition may undergo absorp-
tion, and so completely" disappear; or, if not suitably treated, it may"
pass on to organization, with the formation of nodules and patches of
thickening.

“ The articular structures proper — synovial membrane, cartilage,
and bone — are not primarily affected, but the parts implicated are
the fibrous tissues of the joints, muscles, and bones, especially the
aponeuroses and insertions of the muscles, the muscle sheaths in which
the muscle spindles lie, the bursae, fasciae, the fibrous ligaments and
capsules of the joints, and the periosteum. Such affections cause pain
and stiffness in these structures, are especially apt to recur, and are
commonly" referred to as rheumatic or even gouty in their origin. The
inflamed and swollen fibrous tissue is tender, painful on pressure or on
movement, and can frequently be felt on palpation, or is evident by
the consequent elevation of the skin. Sudden movement of the
affected muscles generally" causes excruciating pain, while the local
pain on pressure is one of the most diagnostic features of these cases.
The indurations may" be widespread, but generally are well defined,
and vary in size from -J- in. to i in. in diameter. They may be situated
in the subcutaneous tissue, the muscles, tendons, aponeuroses, the
capsules and ligaments of the joints, the bursae, the sheaths of the
nerves, and periosteum. The pain is especially aggravated by any
sudden movement of the muscles which compresses or stretches the
afiected fibrous tissues and the sensory nerve filaments.”

The fibrositis may sometimes have a microbial cause ; but in most
cases this cannot be traced, and the chief factors which predispose to
it are cold, damp, and wet ; extremes of heat and cold ; local injuries,
recent or past ; and the absorption of irritating toxins from the
alimentary tract, inflamed tonsils or pharynx, or other focus. Not
infrequently the focus cannot be found, but exacerbations of the

FIBROSmS

238

MEDICAL ANNUAL

toxic factor are indicated by associated symptoms often labelled
febriciila or influenza. The white fibrous tissues in practically any
part of the body may be affected ; but the liability is greater in certain
situations, the most familiar types of the condition being those presented
in the guise of muscular rheumatism,” Dupuytren’s contraction of
the palmar fascia, fibrositis of the plantar fascia, of bursse, or of joints,
and similar affections of the subcutaneous tissues far removed from
joints.

Treatment, — GeneraL — “ A Saline Aperient should always be given
at the onset of an attack of acute fibrositis, and repeated as necessary.
If the attack is a severe one, confinement to bed may be necessaiA", and
it is important to recognize the beneficial influence of Rest in such
cases. For severe attacks of lumbago and intercostal rheumatism,
firm strapping with the brown-holland strapping plaster secures the
necessary local rest of the affected muscles. In all cases of brachial
fibrositis the arm should be carried in a sling, and should be moved as
little as possible during dressing and undressing.

In the treatment of the different forms of fibrositis, salicylates are
of little curative value, as they do not exercise the same specific action
as in acute rheumatism. Aspirin is of decided use for the relief of pain
in severe cases, but it should only be given with that object. It acts
better than sodium salicylate, owing to the fact that the introduction
of the acetyl radicle increases the analgesic action of the salicylic acid.
It probably also exercises a beneficial effect in cases of abnormal
intestinal fermentation. Perhaps the best method of administering
this drug for the I'elief of pain consists in giving 10 gr. of aspirin with
6 gr. of pyramidon in a cachet every four hours. Potassium Iodide is,
in my experience, the most valuable drug in the treatment of fibrositis.
It seems to exercise a direct effect in removing the hyperplasia and
serous exudation in the fibrous tissues. It should always, if possible,
be given in full doses of 10 or 12 gr., and should be combined with
Tonics, such as nux vomica or the compound glycerophosphate syrup.
If the iodide produces severe symptoms of iodism, one of the organic
iodine compounds may be tried. Of these I have found lodipin, in
the form of tablets, extremely useful.

“ Fibrolysin is a chemical combination of thiosinamin and sodium
salicylate, for which the claim has been put forward that it has a
softening effect upon all forms of pathological fibrous tissue. In a
fonner paper I reported on the use of it in a somewhat limited number
of cases of fibrositis, and then gave a somewhat guarded favourable
opinion as to its being of use in properly selected cases.”

He is now obliged to modify this vieAv, for in only 12 out of S3 more
recent cases has the use of the injection been foliov’ed by a cure.

Local . — ” In the earlj" stages of an acute fibrositis, hot Fomentations
are useful. Afterwards, one of the best external applications in my
experience is a mixture of equal parts of Chloral Hydrate, Camphor,
and Menthol. These three substances form a liquid when well rubbed
together. This liquid should be painted over the painful area, and then

NEW TREATMENT 239 FIBROSITIS

be gently nibbed in with the fingers. Some patients find the cold
sensation produced by the menthol objectionable j in such cases the
menthol may be omitted and equal parts of chloral hydrate and
camphor employed, which also form a liquid when rubbed together.
Another useful external application is to paint the painful area with
Tincture of Iodine, and then to apply a hot linseed poultice or a very
hot fomentation. The heat converts the iodine into vapour, which
exercises an anodyne effect, and, probably by absorption, acts directly
on the affected fibrous tissues. In the later stages the Aconite, Bella-
donna, and Chloroform liniment applied on lint is frequently most
beneficial. In cases of a very localized fibrositis, counter-irritation is
sometimes of great use, especially in the form of the Thermo-cautery.

“ In localized forms of fibrositis, and especially where fibrous deposits
occur — such as in lumbago, thickening of the ligamentous and fibrous
structures surrounding or entering into the composition of joints,
deposits in muscles, tendons, and tendon sheaths, and in chronic villous
synovitis of the knees — the most eSective form of local treatment that
I am acquainted with is the employment of Heat, followed by Ionization
of the affected part. Tliis treatment has a very remarkable effect in
causing the absorption of thickened fibrous tissues. If heat is to be
applied to the entire body, the electric-light cabinet bath is the most
convenient form, but in the treatment of localized forms of fibrositis
it is preferable to concentrate the heat on the affected part only, and
I am confident that far better results are obtained from the employment
of dry radiant heat than from the employment of heat alone. C. F.
Bailey considers that the ideal type of radiant heat should be as nearly
as possible like sunlight, and should give a spectrum ranging from the
ultia-red to the ultra-violet. This type of spectrum can apparently
only be obtained from lamps of a very high candle-power, such as the
so-called lencodescent radiant-heat apparatus, which consists of a
single 500-candle-power lamp in a funnel-shaped projector lined with
a reflecting surface. The method of applying the heat is to sway the
lamp slowly backwards and forwards over the affected part for about
twenty minutes. It must be applied directly to the skin, and anything
like a severe burning sensation should be obviated either by the
temporary removal of the lamp or by brushing Avith the hand that part
of the surface which is being treated. When the lamp is switched off,
the part feels burning hot to the touch, and the surface is red and
mottled from A'ascular dilatation. If such radiant heat alone is used,
it very definitely relieves pain, softens fibrous indurations, and causes
improvement in joints and their surroundings as regards flexibility
and reduction in size. These results are, however, considerably
enhanced by subsequent ionization.

“ The exposure to heat should be followed immediately by ionization
with iodine ions. The iodine is introduced into the affected tissues
from a 2 per cent solution of lithium iodide, to which sufficient liniment
of iodine has been added to give the fluid a sherry colour and so ensure
the presence of an excess of iodine, l^ads of lint six-fold thick are

FIBROSmS

240

MEDICAL ANNUAL

soaked in the hot solution and applied to the part to be treated* A
copper chainmail electrode is then spread over the pad and bandaged
on, leaving the connection exposed, which is then attached to the
negative pole. The positive pole is similarly connected to another pad
soaked in a weak solution of common salt or of lithium carbonate.
Another method, though not so efficacious as the employment of
lithium iodide, is to paint the skin of the affected part with iodine
liniment, and apply a pad soaked in a weak solutionof lithium carbonate
with the electrode connected with the negative pole, the positi\'e being
applied as before. The strength of the current that should be employed
varies with individual patients, but should range from 15 to 40 milli-
amperes. The ionization lasts for twenty minutes, and should be
repeated dail^r if the skin will stand the treatment ; otherwise it should
be used on alternate days. Many patients improve rapidly from
the first, but in severe cases a course of daily applications for four
weeks is required. While this ionization treatment is being carried
out, it is very important that the administration of potassium iodide
by the mouth should be continued.

“ In cases of acute fibrositis, especially in acute lumbago and painful
affections of the knees, shoulders, and elbows, it is advisable at the
first two or three sittings to employ a 2 per cent solution of sodium
salicylate in place of the lithium iodide, in order to produce immediate
relief of the severe pain. The salicyl ion is introduced into the painful
region, and it is remarkable how rapidly it will relieve the pain, just
as salicyl ionization relieves severe neuralgia and some forms of
neuritis.’*

Some observers have stated that the chlorine ion is quite as efficacious
as the iodine ion, and is less caustic, but Luff’s experience is that the
iodine ion is more effective, and he has never met with an}- bad effects
from its causticity. The improvement started by a short course of
heat and ionization treatment will continue to progress for some days
after the treatment is left off.

“ In cases of lumbago, the Static Wave Current may be substituted
for ionization. F. H. Humphris records excellent results with this
form of treatment. It produces a local vibratory effect, and muscular
contraction takes place, so that the wave current tends to remove the
infiltration by squeezing out the serous exudation from the affected
tissues, and thereby relieving the pain. From my experience of a
number of cases that I have had successfully treated, I can thoroughly
recommend the employment of local heat, followed by the use of the
static wave current.

Massage is very useful in the later stages, but it should only be
employed when it causes no pain. The manipulations should be very
gentle at first, so as to promote removal of exudation and to relie^^e
the tension. Afterwards more vigorous massage is most efficacious in
dispersing the indurations and fibrous thickenings, and in removing
the stiffness of the affected parts. General massage should not be
employed, but the tender and affected areas should be carefully marked

NEW TREATMENT 24I FOOT-AND-MOUTH DISEASE

out for treatment. Massage sliould not be used to affected joints, but
only around them, so as to improve the circulation in their neighbour-
hood.

During the very painful stage of muscular rheumatism, as complete
rest as possible of the affected muscles must be enforced, but later on
Exercises of the muscles are of great benefit. Either light dumb-bells
or Indian clubs, of from i lb. to. 2 lb. in weight, should be employed,
and such movements are to be performed as will bring the affected
muscles into action. The exercises should be performed on rising in
the morning, and should not occup}^ more than from ten to fifteen
minutes. A cold or tepid bath should be taken afterwards, and the
skin be briskly rubbed with a rough towel.

“ In cases of chronic subcutaneous fibrosis in very fat people
(adiposis dolorosa), massage is quite ineffective, and often unbearably
painful. In such cases it is essential, first of all, to get lid of the
superabundant fat by means of a strict diet, and b}^ the administration
of Thyroid Gland.

Spa Treatment is most useful in protracted cases of fibrositis, especi-
ally when the waters are strongly radio-active. No special dieting is
required in these affections. Moderation should be the keynote of
all prone to the various forms of fibrositis, and especially should they
avoid foods which their experience has taught them to be apt to
produce gastro-intestinal fermentation. With regard to the under-
clothing that should be worn by rheumatic individuals, porous linen
underwear is the most suitable. Some individuals find that in winter
linen underwear is too cool, and in such cases a thin silk vest may be
worn over the linen. This will be found to constitute a thoroughly
wann, comfortable, and safe form of underwear.

The most suitable soil is gravel, sandstone, or rock, at a fair elevation,
and with good subsoil drainage. Houses should be built on a bed of
concrete, so as to prevent entirely the entrance of ground air. Resi-
dence on a clay soil should be avoided if possible, but in Luff’s experience
the worst soil of all is a shallow gravel soil in a cup or depression of clay,
which allows the subsoil water to accumulate and frequently to reach
close to the surface. Many of the gravel sites lauded by house agents
are veritable traps for the development of fibrositis.

Reference. — IMed. Jour. 1913, i, 756.

FOOT-AND-MOUTH DISEASE. Herbert French, M.D., F.R.C.P.

O’Brien^ records a case of foot and mouth disease as it affected a
veterinary inspector, the source of infection having been a sheep-bite.
Three weeks after, an abscess developed, and a little later, redness
and swelling of both hands and fingers, accompanied by great itching
of the parts, with a few small raised white swellings like little lumps
under the skin, especially round the nails. Shortly afterwards similar
irritation spread to both feet, accompanied by a sensation of pin-pricks
in the soles. The fingers and the dorsal aspect of both hands became
markedly swollen, and covered over with a dull raised reddish rash,

FOOT-AND-MOUTH DISEASE 242

MEDICAL ANNUAL

which Stopped short abruptly an inch above the wrist. Immature
vesicles were observed here and there over the surface of the rash,
more especially in the clefts between the fingers and immediately above
and around the nails. There was no perceptible involvement of the
lymphatic glands. Vesicles were also observed on the inside of the
lips, gums, and side of the tongue. IMastication, deglutition, and
talking were painful, saliva was increased in amount, and the voice
less distinct than normal. The temperature never exceeded 100° F.
Seven days later, fresh vesicles had ceased to appear, and the patient
ultimately made a complete recoveiyL

Reference. — ^Med. Press and Circ, 1913, i, 35.

FRACTURES. PriesUey Leech, M.D,, F.R.C.S.

Treatment of Simple Fractures : Report by a Committee of
THE British Medical Association.

The treatment of simple fractures has been thoroughly investigated
by this Committee. The report is a voluminous one, and contains
a mass of statistics, many illustrations, and articles by Lambotte,
Lane, Lucas-Championniere, Steinmann, Bardenheuer, and Schrecker,
on the various methods of treatment. The conclusions to which the
committee came are as follows : —

1. The statistics of the non-operative treatment of fractures of the
shaft of the long bones in children under 15 years of age, with the
exception of both bones of the forearm, show as a rule a high percentage
of good results. The relative figures are : In 1,017 non-operative
cases, 90*5 per cent good functional results ; in 64 operative cases,
93*6 per cent good functional results. It is possible, either by operative
or non-operative treatment, to obtain a high percentage of good results
in children.

2. In comparison with the non-operative results in children, the
aggregate results of non-operative treatment in those over 15 years
of age are not satisfactory.

3. From an analysis of the age groups, the functional result of non-
operative treatment becomes vrorse as the age advances ; the older the
patient the worse the result.

4. In cases treated by immediate operation, the deleterious influence
of age upon the functional result is less marked.

5. In nearly all age groups, operative cases show a higher percentage
of good results than non- operative cases.

6. Although a functional result may be good with an indifferent
anatomcal result, the most certain way to obtain a good functional
result is to secure a good anatomical result.

7. No method, whether non-operative or operative, which does not
definitely promise a good anatomical result, should be accepted as the
method of choice. For this reason, mobilization and massage alone
have not been found to secure a high percentage of good results. They
are, however, valuable supplementary methods of treatment. Similarly,

NEW TREATMENT

243

FRACTURES

operative methods which secure reposition and absolute fixation of the
fragments yield better results than those %vhich do not ; imperfect
fixation of the fragments by ^vire or other suture has been found to be
an unsatisfactory procedure in the treatment of fractures of long bones,
with the exception of the olecranon process of the ulna.

8. Operative treatment should not be regarded as a method to be
employed in consequence of the failure of non-operative treatment,
for the results of secondary operations compare very unfavourably
with those of immediate operations. To secure the most satisfactory
results from operative treatment, it should be resorted to as soon after
the accident as practicable.

9. It is necessary to insist that the operative treatment of fractures
requires special skill and experience, and such facilities and surroundings
as will ensure asepsis. It is therefore not a method to be undertaken
except by those who have constant practice and experience in such
surgical procedures.

10. A considerable proportion of the failures of operative treatment
are due to infection of the wound, a possibility which may occur even
with the best technique.

11. The mortality directly due to the operative treatment of simple
fractures of the long bones has been found to be so small that it cannot
be urged as a sufficient reason against operative treatment.

12. For surgeons and practitioners who are unable to avail them-
selves of the operative method, the non-operative procedures are likely
to remain for some time yet the more safe and serviceable.

Robert Jones® reviews the present position and criticizes the above
report. He is confident, after reading it, that the question is not,
“ Must we prepare ourselves to admit that primary operation is to
become the recognized routine ? but the two very real questions
are, “Can we improve our non-operative technique so as to remove
the discrepancies which are in some instances glaringly apparent ?
and “ Can we lay down any laws to guide us when we ought to operate
at once ? ” Mal-union and non-union are common occurrences, and
are often correlated ; it is of extreme importance to obtain correct
alignment, and this can often be obtained if sufficiently strong traction
is employed. In a femur with much displacement, especially in a
strong muscular subject, it is well to employ a pulle)^ and not to be
satisfied until the affected bone is of equal length with its fellow.
Much can be done in old and obstinate cases by continuous and un-
yielding traction. Another cause of mal-union is inefficient splinting ;
the splint should be so constructed as to allow the continuance of
extension, and prevent any deviation from the normal line; e.g., in
fracture of both tibia and fibula in the middle of the leg, both bones
are naturally slightly bovred, and if they are set too straight the
weight of the body is deflected to the inner side, which involves a
strained internal lateral ligament at the knee and a weak, painful,
everted ankle. A third cause of mal-union is the effect of body w^eight

FRACTURES

^44

MEDICAL ANNEAL

carried too carh^ b}’ newly-united bone ; the time required for complete
consolidation of bone is much longer than is usually thought, as is
shown on the refracture of-mal-united femora by manipulation from two
to four months old. Another cause of mal-union is impatience on the
part of the surgeon. At the end of the fifth week he tests the fracture
and finds it ununited ; if left alone for another fortnight or more,
consolidation would be secured, instead of which, an examination is
made two or three times a week, and the chance of the bone uniting
is diminished. It must be remembered that a small percentage of
fractures require twice as long to consolidate as do the rest. A good
method of hastening union is that introduced by H. O. Thomas, i.e.,
damming and percussion. With a heavy, well-covered mallet, the
fracture ends are beaten, and an indiarubber tube is tied 2 in. or 3 in.
above and also below the fracture. The most obstinate of all ununited
fractures is that which occurs in the tibi^ of small children. They seem
to resist any wire or plating, and prove a veritable nightmare to the
surgeon. In two cases Jones secured firm union by transplanting
a portion of the other tibia between and over the fractured ends.

If we have to operate upon an ununited and mal-united limb,
preliminary traction is very valuable [Plate XVI, Fig. D). An old
overlapping fracture of tibia and fibula, after traction by a pulley,
followed by extension for a week, may be fixed by plate and screws in
much better position, with less loss of bone than if operated upon at
once. Powerful traction is not applied to the best advantage in the
case of a large wound. If an operation is performed, the fragments
should be securely fixed with plates and screws ; if comminuted,
all splintered pieces of bone should be placed in position.

The failures shown in the report, in fractures of the neck of the
femuY, Jones says are startling ; excluding the patients under 26 years
of age, there were only 21 per cent of good functional results. The
Liston splint and the weight and pulley, should be discarded. To
avoid and minimize deformity and obtain a useful limb, it is essential
to treat the limb in the abducted position. The mode of reduction
is simple. A roller towel is placed round the patient's perineum to
counter-extend, while manual traction is applied to the limb, and
continued until the correct length of limb is obtained ; the limb is
rotated inwards until the foot is at right angles to the table, and slowly
abducted under tension. The abduction relieves the muscles which
obstruct reduction and brings the outer fragment on to the inner. This
position can be maintained by plastei-of-Paris bandage, but better still
by an abduction frame [Plate XV I, Fig. A). x\s regards the impaction
of fragments, if there be hardly any shortening and no rotation, it should
be left alone ; if there be eversion and shortening, it should be
reduced at once. In six weeks, a Thomas’s knee-splint is applied with
extensions (Fig. C). In old people, where there is fear of hypostatic
pneumonia, this can be applied from the first, and the patient may
be well propped up. The poor results in the report are due, Jones
thinks, firstly to inefficient reduction of the deformity or to no attempt

Fig, A . — Abduction frame, showing continued
traction and counter-extension.

C . — Thomas's knee splint for fractured femur.

bhowins: method of extension during operation for fracture
with overlapping of lower third of tibia and fibula.

PL A TE

XVII.

FRACTURE OF THE NECK OF THE F E M U R

K — Skiagram showing fracture of the neck of the Tcmnr in a girl 15 years oi age
Three and a half weeks after the accident.

Fi^. /'.—Skiagram t.iken siv month', later, showing testuration of the noinial L'liitour.

MEDICAL AXXrAL, / v/

XEW TREATMENT

245

FRACTURES

at fixation, and secondly to too early attempts at walking. When the
patient begins to w'alk he had better w’ear a w^alking caliper splint
[Fig, B), Plate XVII shows [Fig. E) fracture, and [Fig. F) restora-
tion of contour, of the neck of the femur.

Why is the treatment of fractures of the femoral shaft in the adult
so much less satisfactory than in the child ? Jones asks, on reading
the Committee’s results. He personally treats most cases with a
Thomas’s knee-splint, and he says the great advantages of this splint
are overlooked by prominent surgeons in this country. Obstetric
fracture in the new’-bom is best treated by a small Thomas’s bed-splint.
In certain fractures of the upper third of the femur, when a marked
deflection of the upper fragment occurs the abduction frame may be
advantageously employed. At the end of six weeks the patient gets
up and walks about in a walking caliper. The cause of the bad results
in fracture of the femur, Jones ascribes, not to the w^ay the fracture was
set in the first instance, but to the fact that ow-ing to the pulley and
extension treatment, the thigh muscles contract every time the patient
moves, and over-riding and shortening occur.

As to fractures of leg hones, in those of the tibia alone the results are
fairly good ; they are not so good w^hen both bones are broken, and the
results in cases of Pott’s fracture are very bad, and compare unfavour-
ably with those given by Bardenheuer in the Appendix, and those of
Hitzrot in the Annals of Surgery. A Pott’s fracture should be
reduced at the very earliest opportunity, in spite of swelling or effusion ;
the consequences of dela}^ are serious. To reduce the fracture, the
knee should be well bent, and it may be useful at first to increase the
deformity in order to disentangle the ends. With the foot somewdiat
flexed, the surgeon should pull the heel forwards and push the tibia
backwards until he feels that the dislocation of the ankle is amended.
He should then direct all the force that is needed to over- correct
the valgus slightly. Unless there is a splint fracture of the posterior
portion of the tibia, there is but little tendency to subsequent displace-
ment. Ultimate deformity is due either to insufficient reduction, or to
a giving way of the ankle due to deflection of weight upon the yielding
bone. This may be corrected if recent by wrenching ; if the union is
too firm, osteotomy may be needed.

. In Pott’s fracture, a boot should be worn wdth the inner side raised,
and in some cases with aii outside iron.

In the upper limbs the thing most worthy of notice is that at the elbow
the results of both operative and non-operative treatment give over
40 per cent of failures. Jones recommends treatment in the hyper-
flexed and supinated position ; no change should be made in this
position for two weeks, and then the only change is a lowering of the
wrist for an inch or so. Early movement, even passive, is a great
mistake in these cases. Operative results on the growing epiphysis
are worse than in those not operated on. In fracture of the olecranon
the results of operative and non-operative treatment are nearly the
same. The results in fracture of both bones of the forearm in children

FRACTURES

246

MEDICAL ANNUAL

are less satisfactory’ than they should be. It is a safer proceeding for
those with no great experience in treating fractures, to keep the forearm
well supinated. The results in Colies’s fracture are very poor, only
57 per cent giving good functional results ; the radial deformity
should be corrected completely, but the ulnar prominence is of little
importance ; massage should begin at the end of the third week.

No surgeon can read the report of the Committee, and Mr. Jones’s
criticisms, Avithout being convinced that a part at any rate of the bad
results is due to inefficient treatment, and if suitable non-operative
treatment were applied in the first instance, the results would be better.

Pirie Watson^ reports the results in over 400 simple fractures treated
by massage and movement. The younger the patient, the less massage
is required ; young tissues are exceedingly susceptible to massage,
and react to it quickly. He has used a powder consisting of equal
parts of talc and boric acid as the lubricant ; Lucas-Championniere
prefers olive oil. IMassage is begun at once ; the sittings should not
exceed fifteen minutes, and twenty-four hours should elapse between
them ; after the first nine or ten days they may be at less frequent
intervals. Passive and active movements are also used, passive first and
the active later. They are especially necessary in fractures near joints.
Full amplitude is not necessary?” to prevent adhesion, and the produc-
tion of pain should be avoided. In contradistinction to some surgeons,
he does not believe immediate reduction of a fracture to be necessary,
and states that in some cases this may be postponed with advantage,
since after massage it may’ become much easier to effect reduction.
In Colles’s fracture, contrary to Jones’s procedure, reduction was not
attempted unless the displacement was gross ; if reduction were not
performed, impaction Avas carefully preserved, and Watson states that
practically complete restoration of function Avas obtained in four
Aveeks. Fractures of the elboAv and of the condydes of the humerus
were treated in the flexed position, but passive movements Avere
commenced, being limited to pronation and supination ; flexion and
extension are only allowed when consolidation has occurred.

Operative Treatment of Fractures.

Walker^ reports 21 cases of fracture of the femur Avdiere he used
Lane’s plates after the best efforts of conser\"ative treatment had
failed. He neA’er had a break of the plates, and folloAvs Lane’s
technique. He draAA’s attention to the fact that the plate only
approximates the fragments, and is not sufficient to hold them. He
uses the Lemon extension apparatus and puts a plaster case on the
limb, alloAving this to dry before taking off the extension or removing
the patient from the table. He considers the .r-ray’s Avill indicate the
cases in AA'hich operation is necessary’.

Bartlett,^ of Boston, has used Lane’s plates in 76 cases of A’arious
broken bones. He has traced the history’ of 38, 22 of Avhich Avere simple
and 16 compound; of these latter, 12 AA’ere fresh or granulating, Avhile

NEW TREATMENT

247

FRACTURES

4 were suppurating at the time of operation. Of these 38 patients,
13 are kllo^^^l to have had their plates removed, 4 in simple fracture
cases and 9 in compound ; 7 of the results Bartlett considered to
be failures. The mortality has been 3*9 per cent. In future he
will abstain from general anaesthetics when a functional result merely
is contemplated in a chronic alcoholic, and forego bone-work until
primary shock is past. He is now operating on a smaller percentage
of fractures than he c id at first.

Sweet and Winsor® have carried out some experiments in dogs on
the various methods of operating on fractures. They used two intra-
meduilar\^ and two extramedullary methods, bone dowels or pins, and
silver tube dowels, Lane plates both of steel and steel silver-plated,
and a steel plate fastened with a
special bolt and nut. Their work is
not yet finished, but the folio-wing
points are worth noting : Infection
vitiates the result of any method ;
no method in the dog can prevent
mobility without external splinting,
and mobility is harmful ; a constant
stress such as might be exerted on
a screw by a constant muscle-pull
or by the weight of the limb, will

result in a pressure necrosis of the method ofinserting in position,
bone round the screw. As a deduction

from this, they suggest that every operated fracture should be
treated after plating exactly as though it had not been operated
upon. The use of silver is not recommended, as it has action on the
tissues. Certain considerations favour the bone dowel, but it is
difficult to apply tightly on both fragments, and if it is not tight it
will become a foreign body in the medullary canal, making more
trouble than any other de\dce.

Eliason" experimented with various steel plates and screws, and
came to the conclusion that a G vanadium plate with re-enforced

Fig, 21.'— temur of a cat six weeks after operation, showing
steel peg in position. The bony union is quite firm . — Drawn
from a skiagram.

screw eyes accommoda-
ting four No. 6 screws
one half-inch long
threaded to the head in
a No. 32 drill hole, gave
the strongest union.

Hey Groves® has
made experiments with

intramedullary pegs,

and has also used them clinically. He has employed pegs with a fixed
cross-piece {Figs, 20, 21), which prevents the peg slipping into the
medullary cavity The method of use is shown in the diagrams, but
it can only be applied to those cases where the broken bone fragments
are easily separated from one another, and owing to its shortness, it

FRACTURES

248

MEDICAL ANNUAL

does not exercise much influence in maintaining the straight axis of
the bone. These pegs are 2*4 cm. in length. In the majority of
fractures that require operation, the ends cannot be separated and
these pegs cannot be used ; he has therefore devised a longer peg. 4*7 cm.
long {Fig, 22), perforated in its centre by a hole transverse to its long

axis ; along opposite
sides of the peg run
grooves in its whole
length, and into these
grooves the trans-
\'erse hole opens. A
fine flexible steel wire
is threaded through
the hole, and lies
snugly in the
grooves, so that the
whole peg can be

Fi^, 22.-— (rt) Longer peg, 4*7 cm., grooved at the side to allow the slipped intO One
wire to lie in its length. (/>) Peg in position ready for pulling into <• ,

the right'hand fragment, fragment Of the

bone ; the other

fragment is brought into apposition, and then by traction on the
wire, the peg is pulled into position, so that one half lies in one frag-
ment and the other half in the other. The sizes of the pegs vary
from I to I* in. in diameter, and a drill is used to make a hole in the
bone to fit the pegs. He got a very good result in a fracture of the
upper third of the thigh ; where Lane’s plates are difficult to fix. He
has also used metal pegs of steel and magnesium. The latter leads to
overproduction of callus.

Roberts® thinks that operative fixa-
tion of fractures of the femur is not so
innocuous a proceeding as some medical
men seem willing to assume, and quotes
cases to show that plating may be a
cause of delay in union of the fractured
bones. He records an apposite case,
and quotes the opinions of other sur-
geons on this matter ; and even many
of those in favour of operative treatment
admit that union is delayed, contrary
to the opinion of Lane. He says that
operative treatment is particularly dan-
gerous when adopted by no\dces in
aseptic surgery or in places where com-
plete asepsis cannot be obtained.

Fracture of Neck of Femur . — Royal Whitman^® again draws attention
to the ahdnciion ireafnient. This method seems to have been neglected
in England, and Jones of Liverpool {vide supra) is the only surgeon
who gives it much consideration. The method is a sound one, based

NEW TREATMENT 249 FRACTURES

on anatomical and pathological grounds, and gives good results.
Perhaps one reason why it has been neglected is that the text-books
and surgical tradition have been in favour of the view that much
cannot be done for this fracture. This is a mistake, and Whitman’s
method should be tried before attempts are made at any operative
treatment. The results of the latter
have not been so good as some of
its advocates make out, and the risks
are certainl^^ greater. The anatomical
basis of the treatment is this : the
normal inclination of the neck of the
femur of about 130° permits a range
of abduction at the hip of about 40°
to 50° (Ffg. 23). During the move-
ment of abduction the head of the
femur glides downwards until the
io\ver third emerges from the aceta-
bulum and distends the lower part
of the capsule {Fig. 24). At the limit
of abduction under anaesthesia, the
base of the neck is in contact with the rim of the acetabulum, the
tissues co\^ering the trochanter are apposed to the tissues covering
the pelvis, and the capsule is tense. Any change from the normal,
either in the forward, backward, or upward inclination of the femoral
neck, must_^induce a corresponding change in function ; e.g., shorten-
ing of the neck, or loss of its normal angle,
would limit the range of abduction, and this
is always present after fracture of the neck of
the femur treated in the conventional manner,
even when union has been obtained.

In complete fracture of the neck of the
femur the limb is usually shortened, somewhat
flexed, rotated outw^ards and often slightly
abducted {Fig. 25). Thus, the outer fragment
is turned forwards, displaced upwards, and
usually lies on a low’er plane than the head.
As one has no conti'ol over the inner fragment,
contact can be assured only by adjusting the
outer fragment to it {Figs. 26, 27). This is
accomplished as follows : The patient, having
been anassthetized, is lifted on to a sacral
support, the shoulders resting on a box of
equal height, while the extended limbs are
supported by two assistants. The assistant
holding the sound limb then abducts it to the anatomical limit to
illustrate the normal range, which varies in different individuals and at
different ages, and incidentalh^ to fix the pelvis by direct bony con-
tact. The operator first flexes the thigh to disengage the fragments ;

24. — ll’itst rating the three checks to
abduction : Tension on the capsule ; con-
tact of the neck and acetabulum ; and
contact of the trochanter and pelvis.

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250

MEDICAL ANNUAL

the assistant then extends the limb, and by manual traction over-
comes the shortening as
demonstrated by the
relation of the trochanter
to Nelaton’s line and by
measurement ; he then
rotates it inwards, and
under traction abducts
it to the normal limit,
the operator meanwhile
lifting the thigh from
beneath. Inspection
should now show
absolute correspondence
between the extended
limbs as to abduction,
rotation, length and
position of the ti'ochan-
ters. In this position the
limb is fixed by a plaster
spica extending from the
nipples to the toes {Plate
XVIII, Eig, A).

True impaction of this fracture must be infrequent, and could only
be caused by direct violence. What passes
for impaction is usually a fracture with but
slight displacement {Fig^ 28) ; clinically, a
case in which shortening is slight, crepitus
absent, and in which some control of motion
or even capacity for weight-bearing is
retained. These cases may be treated in
the same manner. Another type of so-
called impaction is the incomplete fracture,
the neck being depressed by the opening of
a wedge-shaped interval in its upper border
{Fig, 29) ; this is most common in childhood,
but it is by no means limited to early life.

Such and similar deformities may be
corrected as follows. As normal abduction
depends upon the upward inclination of^the
neck, it must be limited in direct proportion
to the lessened or lost angle. Thus the
range of abduction under anaesthesia is
checked by contact of the neck with the upper border of the aceta-
bulum, a contact that fixes it ; now, under stead}" traction aided by
downward pressure on the projecting trochanter, the limb is still
further abducted, wfith the aim of overcoming or lessening the
deformity. In other words, the deformed neck lies in a plane

27. — The deformity reduced
by the abduction method. Show-
ing the relaxation of muscular
tension and the security assured
by the attitude.

trating the reduction of the deformity by direct traction
and abduction. The ojperator supports the joint. The
left limb is abducted to indicate the normal range, which
varies in different subjects, and to prevent tilting of the
pelvis.

PLATE XVIII.

WHfT.'lVlAN’S METHOD OF TREATING FRACTURE OF THE
NECK OF THE FEMUR

r — Plaster spica, showing adjustment to the pelvis.

B . — Hip splint, to permit walking without weight-bearing,
used during period of convalescence.

'if Bn /CAL ANNUAL, JQ14

NEW TREATMENT

251

FRACTURES

representing normal abduction, while the shaft is in the middle line.
The shaft is therefore abducted until the normal relation is restored,
at least to the degree that is practicable. When this is accomplished,

F 4 ’* 2S. — A form of complete fracture,

often classed as impiacted, in which defor- Fig. 29. — A form of incomplete fracture,

mity may be easily corrected by traction with deformity which may be easily cor-
and* abduction. rected by the abduction method.

the outward rotation having been reduced, a plaster spica is immedi-

ately applied [Plate XVIII, Fig. A). In the classical but unusual
cases of true impaction in which the neck is shortened, corrective

manipulation may not be indicated.

This injury is not uncommon
in early life, but is rarely seen by
writers on fractures because the
patients are not sent to hospitals.
In general there are two classes
of fractures [a) that of the neck,
(6) that at the epiphyseal junction.
The first is very similar to that
seen in adult life, except that it is
often incomplete, and that, if un-
treated, union with deformity (coxa
vara) is the rule. The epiphyseal
variety is limited to adolescence,
and although it is not uncommon
in normal subjects as the result of
direct violence, a large proportion
of the patients are of the weak,
rapidly-growing, or over-weighted
t3^pe. The injury is usually slight,
causing an in fracture rather than a
separation. The patient usually

I 4

Fig. 30. — Diagrams illustrating W'hitman’s ,
abduction method of reducing deformity of the
fracture of the neck and at the epiphyseal
junction, which appeared in the Annals 0/
Surgerv, November, igos.

walks about complaining of stiffness and limp, the deformity of

the bone graduallj^ increasing until, after further injury or overstrain^

FRACTURES

252

MEDICAL ANNUAL

the disability may become complete. The majority of cases now
classified as unilateral coxa vara are of this tj’pe. In the treatment
of both types the abduction method is essential. In the epiphyseal
form, the manipulations of flexion, abduction, and inward rotation
must be forcible and persistent, and if the case is of long standing,
with forward and upward displacement of the neck in relation to the
head, an open operation is required to appose the fragments properly
[Fig. 31). The plaster is kept on eight to twelve weeks, or even
longer. Crutches are used when the patient has regained sufficient
strength and confidence to make locomotion safe, ^^'eight-bearing
must not be permitted until sufflcient time has elapsed to ensure firm

union, confirmed if possible by
.r-ray pictures. {See Plate XVIII,
Fig. B.) The open operation is
rarely indicated primarily, except
in the epiphyseal type of fracture
in which the fragments are dis-
placed and adherent. It is indi-
cated for non-union in suitable
cases. The joint is opened by an
anterior incision from the anterior-
superior spine to the base of the
neck. The fragments are fresh-
ened apposed, and fixed in contact
for a sufficient time by a drill
passed through the shaft and neck,
and into the head. In cases of
long standing in which union is
impossible, the head should be
removed and the trochanter im-
planted and fixed in the acetabulum to assure the capacity for
weight-bearing at the expense of movement.

Worms and Hamant^^ review very thoroughly the fractures of the
neck of the femur in childhood and adolescence. Before the intro-
duction of the .r-rays this fracture was not believed to exist in childhood
and adolescence except as an epiphyseal separation. The authors
consider that at the present time the existence of these fractures must
be admitted. They have made some experiments on the dead bodies of
children from one to fifteen years of age, and they say that fracture
is as frequent as separation of the epiphysis. They come to the con-
clusion that the fractures may be complete or incomplete, and may
terminate in union with good function, union in a faulty position, or
non-union ; and that traumatic coxa vara is one result of such fractures.

Fractures about the Wrist . — Knox and Salmond^- have analyzed the
radiographic findings in 214 cases of injuries to the bones of the wrist.
These were divided into two classes : {a) those in which the lower
epiphyses of the radius and ulna have joined their shafts, and [b) those
in which they have not yet joined, 150 cases belonging to the first

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253

FRACTURES

series and 64 to the second. The first corresponds rougWy with persons
above the age of twenty, and the second with persons below that age.
From an analysis it appears that the most common injury at the wrist
in the first series of cases is a transverse fracture one half -inch above
the lo'vver end of the radius, the lower fragment being displaced back-
w^ards, and with or without a fracture of the styloid process of the ulna ;
in cases of the second series, where the epiphyses are not yet united, the
commonest injury'- is a trans\’erse fracture about one inch above the
low^er ends of both forearm bones and with both low^er fragments
displaced backw^ards.

CampbelP^ reports three cases of fracture of the carpal scaphoid
with involvement of the median nerve. In two of the cases the fracture
was caused by sudden over-extension of the wTist, and it was thought
that the median nerve had been overstretched ; probably also one of
the fragments was pressing on the nerve.

Wallace^^ has investigated the injuries caused by h^^perextension
of the wTist and “ back fire ’’ w-hen starting a motor car. The con-
clusion he comes to are that the following injuries may result : fracture
of the scaphoid, dislocation of the semi-lunar, backw^ard dislocation
of the os magnum, the unciform, and the os pyramidale, and transverse
and vertical fractures of the radius.

Fracture of the Ulna with Dislocation of the Head of the Radius . —
Ashhurst,^® of Philadelphia, says this combined injury is not so rare
as is believed ,* often the luxation of the radius is overlooked though
the fracture of the ulna is usually recognized. In every fracture of
the ulna, dislocation of the radius should be looked for, and vice versa.
In 140 instances of this combined injury there w^ere 15 examples of
nerve injury ; in 2 of these, musculospiral paralysis appeared to
have developed immediately after the injury ; in most cases, however,
it seems to have arisen later, being due to a secondary neuritis from
pressure on the nerve in stretching over the displaced radial head.
Immediate reduction is therefore necessary, and if this be obtained, the
ulna fracture as a rule wdll heal in good position without further trouble ;
if reduction be not obtained, the ulnar fragments wdil overlap or angu-
late, and union wdth deformity, or non-union, will result.

In recent cases with irreducible luxation, the surgeon should resort
to arthrotomy if reduction is impossible by manipulation, the object
being to remove the torn capsule from its obstructing position in front
of the capitellum of the humerus and from over the lesser sigmoid
cavity of the ulna, and to suture it round the head of the radius. In
adults, if irreducible, the head. of the radius should be excised, as
if left it is very apt to lead to dystrophic arthritis.

Of old cases with unreduced luxation he collected twenty -seven. The
treatment is to reduce wdth arthrotomy if possible ; if this is impossible,
as it may be if the ulna has united in a bad position, the head of the
radius should be excised, unless the deformity in the ulna is extreme,
when osteotomy of the latter bone may be done. In old cases with
non-union of the uhia, the ulnar fracture should be exposed first,

FRACTURES

'254

MEDICAL ANNUAL

after freeing the fragments, reduction of the dislocation secured (by
arthrotomy if necessary, including capsulorrhaphy) ; the ulnar fracture
being then treated as if no dislocation had existed.

Kirmisson,^*^ in an article on this lesion, says that the fracture is
nothing, but the luxation is everything.^ He thinks that the riding
of the fragments of the ulna is due to the shortening of the forearm
from the dislocation upwards of the radius, and if this is reduced the
fracture of the ulna is easily replaced. In children, if the ulna has
united in good position and the movements are good, the radius should
be left alone. Abadie^’ believes that the dislocation of the radius is
not the obstacle to reduction of the fracture, but the dentated form
and overriding of the ulnar fragments.

References. — Med. Jour. 1912, ii, 1505 ; Hhid. 1589 ; ^Edin. Med.
Jotir. 1912, ii, 319 ; ^Ann. Sttrg. 1912, ii, 847 ; ^Bost. Med. and Siirg. Jour.
1913, i. 149; ^Ther. Gaz. 1913, 39b; Ibid, 323; Med. Jour. 1912,

ii, 1102; ^Ann. Stirg. 1913. i, 545; ^^Lancei, 1913, i, 1649; ^'^Rev. de Chir.

1912, ii, 416; 1912, ii, 1213; '^^Ibid. 1296; ^^Ibid. 1913, i, 1S19 ;

Surg. 1912, ii, 631 ; Presse MM, 1912. 729. and 19x3; 283. Ibid.

1913, 49.

FURUNCULOSIS. [See also Skin, General Therapeutics of.)

E. Graham Little, M.D., F.R.C.P.
J. and R. J. Reynolds^ recommend the administration of Acid.
Sulph. Dil. (B.P.) in 20- to 30-min. doses, diluted with 2 oz. of water,
every four hours, in the treatment of carbuncle and boils, the only
external dressing used being carbolized vaseline. Stephens^ claims
that Colloid Mercury (a fine suspension of metallic mercury in water,
produced by electrolysis) applied locally to septic areas, like boils and
carbuncles, brings about an immediate cessation of the inflammation.
The part to be treated must first be cleansed with ether or chloroform.
References. — ^Lancet, 1913, i, 749 ; ~Duh, Med. Jour. i9i3» 15-

GANGRENE COMPLICATING GENERAL INFECTIONS.

Herbert French, M.D., F.R.C.P.
Gangrene of the fingers is not common ; the simplest examples are
seen in Raynaud’s disease and in syringomyelia. An altogether
different type has been described recently, however, as a complication
of pneumonia and other infective processes. Two examples are given
in detail by Harttaag^ under the title of spontaneous symmetrical dry
gangrene of the index fingers. Both occurred as a complication of
acute inflammatory’’ processes in the lungs, and arteriosclerosis could
be excluded. The symmetry^ of the gangrene suggested that it was
the result of toxins acting through the vasomotor nerv^es.

Reference. — ^Berl. klin. Woch. 1913, 161-162.

GANGRENE, SURGERY OF. [See also Diabetes Mellitus.)

Priestley Leech, fl/.Z)., F.R.C.S.
Cramp, 1 of New York, gives a resume of the literature of emphy-
sematous gangrene, and reports twenty^-five new cases. Many^ names
have been given it, and he prefers to call it gas bacillus infection, as it

NEW TREATMENT

255

GASTRIC ULCER

is due to infection 'v\nth B. aerogenes capsulatiis. He considers that
the cases reported as due to the vibrion septique will be proved to be
identical. It occurs most commonly in wounds where great trauma
has been exercised, e.g., compound fractures, extensive lacerations,
crushes, and grinding accidents ; three cases resulted from the bite of
animals, several from obstetric cases and operations around the
perineum, a few from subcutaneous injections, and one from tooth
extraction. In the group of 25 cases collected at Belle Vue Hospital,
B, aerogenes capsulaiits was found in 15 ; it was not searched for
in the others. The gross mortality was 44 per cent. Eight of the
25 cases, of which 5 were of a pronounced type, were treated by
incisions and continuous irrigation or baths, with no deaths ; 5
were treated by free incisions and peroxide of hydrogen continuously
administered locally. Pus is seldom present, and the commencement
is very insidious. The incubation is short. The disease may be
divided into superficial and deep types. The latter requires prompt
and energetic action ; oxygen, preferably in the form of hydrogen
peroxide, should be used, but not in full strength or in confined spaces,
or injected directly into the tissues. The incisions should be free,
and if amputation has to be performed, spinal anaesthesia should be
employed in place of general anaesthesia. Early recognition is the
key-note of success in combating the condition ; smears should be
made from the original wound, and not from some point distant from
it, as the bacillus is often only found near the former.

Amputation in Gangrene of the Extremities . — Ehrlich and Maresch®
give the results of a study of 81 cases of gangrene in von Eiselsberg’s
clinic in Vienna. Of these cases, 44 were the result of arterio-
sclerosis and 29 were due to diabetes. In cases of gangrene of the foot
due to arteriosclerosis, if the general condition is good, separation of
the toe may be waited for ; exarticulation in the neighbourhood of
the foot is not to be recommended. If a hne of demarcation does not
form, or the gangrene spreads, or septic complications ensue, or un-
bearable pain is present, amputation in the thigh should be performed
in old people. In younger people, in some cases amputation of the
leg may give good results if the popliteal pulse is present and the stump
bleeds freely. In diabetics, if amputation is done it must be in the
thigh. In all other forms, if there is no diffuse or progressive gangrene,
e.g., after burns, wounds, or frostbites, it is best to wait in young people
for a line of demarcation to form, unless septic processes compel an
early interference.

References. — Surg. 1912, ii, 544; ^Wien. kiin. Woch. 1913, 105S.

GASTRIC ULCER. [See also Stomach and Duodenum, Surgery' of.)

Robert Hutchison, M.D., F.R.C.P.

Pathology. — Bolton,^ as the result of his further researches into
the mode of origin of chronic ulcer of the stomach, is persuaded that
chronic ulcer arises always by the extension of an unhealed acute ulcer.
" The funnel shape of an ulcer is not due to the fact that it arises as a

GASTRIC ULCER

•256

MEDICAL ANNUAL

result of vascular occlusion ; it is merely the result of the mode of
spread of the ulcer, which occurs in two directions, laterall5’ and in the
depth. If lateral extension has occurred rapidly, the funnel is^a very
shallow one, and this shape disappears when the muscular coat is
destro5’ed, the ulcer assuming a flattened form. If extension has
occurred chiefly in the depth, the funnel shape is well marked and per-
foration soon occurs, unless there is a well-marked inflammatory
reaction and thickening. Digestion of the sides of the ulcer under-
mines the edges, so that the fiat variety acquires a raised and overhang-
ing edge, and the funnel-shaped ulcer is converted into a globular or
other irregular-shaped cavity.

“ Chronic ulcer probably always arises in this manner, because, so
far as we know at present, every initial lesion leading to ulcer is essen-
tially acute and produces in the first instance acute ulcer. According
to the nature of this initial lesion there are sei^erai difierent types of
acute ulcer. The3' are all, under suitable circumstances veiy little
understood at present, able to spread and become chronic, but there
is undoubtedly one particular type of acute ulcer which most frequently
undergoes these changes.

Acute ulcer, w-hatever its origin, tends to heal rapidly and com-
pletely within a few weeks, and perhaps there is one type which most
commonly does this. Occasionally, without showing any tendency to
spread, an acute ulcer may be dela3’ed or arrested in its healing, when
thickeiiing occurs and the condition ma}^ become chronic.'"

Friedenwald,^ from a statistical study' of 1000 cases of gastric
carcinoma, is unable to agree with the sweeping statements that have
been made as to the frequency with which ulcer becomes transformed
into cancer. He considers that this does not take place in more, and
probably in less, than 23 per cent of cases of ulcer.

Symptomatology. — Smithies^ has studied the symptoms in 140
cases of gastric ulcer without food retention which were all demonstrated
at operation. He finds that in more than one-third of such cases,

■ the stomach’s emptying power is maintained. Of this group of ulcers,
92 per cent occur between the ages of thirty and sixty. Males aro
affected three times as fi'equently as females. Nearly three-fourths
of the cases have "spells” or "attacks” of discomfort, with good
health between. Such a history may^ extend over thirty years
without alarming clinical manifestations. The attacks are usually
called " biliousness ” or " dyspepsia.” They often show a peculiar
seasonal relation. In 36 per cent, the disability is continuous, with
or without nutritional disturbances.

Abdominal pain or distress is a constant symptom. It is " colicky ”
in nature in more than 22 per cent of cases, requiring hypodermic
medication in 12*7 per cent. It is frequently' mistaken for appendix
or gall-bladder disease, and is often associated with such in addition
to gastric ulcer. Night pain, with interference with sleep, is present
in 19*2 per cent of cases. Eighty per cent of patients complain of
epigastric distress, frequently referred to the right rib margin, or the

NEW TREATMENT

-57

GASTRIC ULCER

back. In 87*8 per cent of proved ulcers, pain or distress has definite
relation to food ingestion. Eighty-three per cent of cases show pain
or distress coming on within four hours following eating. Nearly two-
thirds of pyloric ulcer cases have discomfort from two to four hours
after eating, more than one-half of lesser curvature ulcers from one to
three hours after, more than two-thirds of posterior wall ulcers within
three hours after, and more than two-thirds of ulcers near the cardia,
less than two hours after eating, while in more than 44 per cent of this
class it is less than one hour after. Discomfort is most frequently
controlled by ingestion of food and alkalies, and by vomiting.

1 2 *2 per cent required morphine.

On palpation, epigastric tenderness is exhibited in 95 per cent of
cases. In more than three-fourths, tenderness was most marked in
the right upper abdominal quadrant. 2*8 per cent of cases shovred
palpable ridges. More than four-fifths of the ulcers were located at
the pyloric half of the stomach, and this was in general the anatomical
area of greatest complaint or distress on examination. The diagnosis
of the character of ulcer to be found on exploration is only possible
where a careful anamnesis is made.

Vomiting is present in nearly three-fourths of gastric ulcers without
food retention. About 17 per cent vomit food. Only rarely is delayed
vomiting observed. Vomiting is induced in more than 10 per cent of
cases to relieve pain. Nearly 40 per cent of patients vomit regularly.

Waterbrash is a prominent feature in 19 per cent; pyrosis and
eructation in 87*8 per cent. In nearly one -third of the cases, vomiting
comes at the time of maximum abdominal distress. In 28 per cent
the ingestion of food precipitates vomiting ; more than 53 per cent
vomit within three hours after eating. In 7 per cent night vomiting
is a feature. Ulcers at the pyloric half of the stomach are most com-
monly associated, with vomiting, even when there is no interference
with the emptying power of the stomach.

Of 140 proved ulcers in this group, bleeding (haematemesis or melaena)
was noted in but 407 per cent. About one-fourth of the cases had
haematemesis alone, one-third haematemesis with or without melaena,
while 7*1 per cent had melaena alone.

Test-meal Findings . — Irrespective of location of the ulcers, the
average total acidity was 55 ; the average free HCl, 42*5 ; the
“ combined ” HCl in 82 per cent of cases between 10 and 20.
Total acidity is most commonly higher in ulcers involving the lesser
curvature and anterior wall than where other parts of the stomach are
affected. High free HCl is noticeably more frequent where the ulcer
is at the pylorus. While high free HCl is usual in cases in the third
decade of life, this is not the rule.

Operative Findings . — More than two-fifths of the ulcers were at the
pylorus. Of 50 ulcers microscopically examined in this series, 24 per
cent showed active inflammatory change, 12 per cent early carcinoma.
In 35 per cent of cases, diseased appendix was associated with
gastric ulcer. In 15 per cent, cholecystitis and cholelithiasis were

GASTRIC ULCER 258 lUEnrCAL ANNUAL

demonstrated as concomitant processes. In nearly t^vo-thirds of this
group of gastric ulcers, diseased appendix and gall-bladder were
re^realed. In vieAv of these figures it is evident that all laparotomies
should be thoroughly exploratoiy?, even when a well-marked gastric
ulcer has been demonstrated.

Diagnosis. — Friedenwald and Baetjer*^ believe that they are justified
in drawing the following conclusions from their study of the x-ray
diagnosis of gastric and duodenal ulcer. It offers most valuable
assistance as an aid in the diagnosis of peptic ulcer ; and although not
3^et sufficiently well developed to be relied upon alone without entering
into the clinical aspect of the disease, it is of the greatest diagnostic
help in obscure cases. In duodenal ulcer there is an excessive hyper-
motility of the stomach, with rapid evacuation of the contents, so
that the greater portion of the gastric contents is emptied within
the first half-hour ; there is hypermotility of the duodenum, with
formation, usualh^ of a vacant area, which remains fixed in all the
examinations.

The diagnosis of gastric ulcer can only be made in certain situations ;
that is, when the lesion is situated on the anterior surface of the stomach,
and along the anterior surface of the lesser and greater curvature. In
this condition there is an excessive irritation from the ulcer, with a
consequent hypermotility, and a spastic condition of the pylorus, so
that for the time being there is practically no expulsion of the bismuth.
It is only when the spasticity relaxes that a portion of the bismuth is
expelled. In gastric ulcer, whatever its situation, we can always look
for retention of contents. In certain instances there is a vacant area
in the pylorus ; there is frequently a tendency to hour-glass formation.

The A'-ray affords an almost absolute means of differentiating between
gastric and duodenal ulcer. ‘ By means of it the presence of a duodenal
ulcer can be positivel37 ruled out. The degree of healing of an ulcer
can thus be more certainly determined than b}" an\^ other \va,y.

Treatment. — Prof. v. Bergmann^ recommends highly a thorough
course of Atropine (J to i mgram in pill thrice dail^-) in the treatment
of gastric ulcer. It promptl^^ relieves pain and, he believes, favours
the healing of the ulcer abolishing muscular spasm. It also lessens
the secretion of gastric juice.

References. — ^ Quart. Jour. Med. 1912, 429; “Bost. Med. and Sttrg.
Jour.igi^ i, 796 ; Kinier. Jour. Med. Sci. ii, 480; “^Mimch.

nied. Woch. 1913, i6g.

GENERAL PARALYSIS OF INSANE. {See Syphilis, Cerebrospinal.)

GLANDERS. Leonard Rogers, M.D., F.R.C.P,

A. Whitmore^ has described under the name of pseudo-glanders a
peculiar fatal disease of not uncommon occurrence in Rangoon, where
he met with it in the post-mortem room, and at first thought it was true
glanders, with numerous small patches of consolidation in the lungs.
On making cultures and stud^dng the bacillus obtained, it was found
that it differed in important details from B. mallei, growing rapidty on

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259

GLAUCOMA

peptone agar, producing early wTinkling on glycerin agar, a pellicle on
broth, a tangled mass of long filamentous bacilli upon salted agar,
while young cultures show an active serpentine motility. Animals
can readily be infected by feeding experiments. In other cases the
organism was recovered from the spleen and blood, showing it to be a
septicaemia, while in a few cases the lung lesions were absent. The
subjects were nearly all very poor, and addicted to injections of morphia
or cocaine ; most of the lesions were found in medico-legal subjects,
so very little information regarding the clinical aspects of the disease
are yet available. One case, however, occurred in the gaol under favour-
able sanitary conditions.

Reference. — Med. Jour. 1912, ii, 1306, and Jour, of Hyg. 1913.

GLANDULAR FEVER. E. W. Goodall, M.D.

E. P. Baumann,^ of Johannesburg, states that he has seen several
cases of this disease, and that “it is a common disease, although not
at all well recognized by the profession. He sums up the diagnosis
of a well-advanced case as follows : “ (i) Pyrexia ; (2) Enlargement
of the cervical and other lymphatic glands — at first unilateral and
confined to the left anterior triangle ; (3) Immobility of the head, with
occasional slight dysphagia ; (4) Enlargement of the liver and spleen ;
(5) Extreme debility and depression ; and (6) Obstinate constipation.'*

Reference. — ^S. Afr. Med. Rec. 1913, 303.

GLAUCOMA. A. Hugh Thompson, M.D.

Of all the newer operations for this condition, it would seem that the
one that has most certainly come to stay is that of Trephining the
Sclero-corneal Limbus. This method was sufficiently described in the
Medical Annual, T913. It Avill be sufficient now to add some further
points d^a^\^l from the experience of Col. Elliot, of Madras, with whose
name this operation will always be associated. The first trephining
for glaucoma in Madras was performed in August, 1909 ; and so com-
pletely did it supplant all other operations in that clinic, that five years
later, at the International Congress of 1913, Elliot was able to read a
paper based on an experience of over S20 cases. ^ The trephining
should, in most cases, he says, be performed in the upper quadrant of
the eye. The conjunctival flap should be large. Its extremities
should be at least 4 mm. from the limbus. “ This is an important
detail, for even if the line of incision should cicatrize down all round,
filtering fluid from the interior of the eye can still find a free exit through
the trephine hole into the subconjunctival tissue outside the incision
limits through the areas left on each side." In the middle third of the
wound, the subconjunctival tissue should be cleared down to the limbus
with scissor points. As soon as the limbus is defined, the anterior layer
of the cornea is split for i or 2 mm. by means of some sharp instrument
(Elliot uses a Bowman's needle), great care being taken not to button-
hole the flap. Elliot's^ reason for laying so much stress on this small
variation of the technique is that he believes the point to be crucial.

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One may, he says and often can, trephine successfully outside the
limbus ; but if one desires to operate with an assurance of success, one
must place the trephine hole as far forward as possible. Only thus
can one be confident ot a direct entry into the anterior chamber,
unhampered by any adhesions which may be present between the iris
base and the corneal periphery. It is advisable to lean slightly on the
comeal edge of the trephine, so that, when that is cut through, the
hinge which attaches the disc may be on the scleral side. This can be
cut through with sharp-pointed iridectomy scissors.

A peripheral iridectomy must be performed in all cases, and as in
most the iris prolapses into the trephine hole at once, it is recommended
by Elliot to seize it, along with the disc, in one grasp of the forceps, and
divide them with a single scissors cut. The iridectomy vfill be either
a peripheral buttonhole or a complete iridectomy extending to the
margin, according to the extent of the prolapse that takes place. As
to the size of the trephine blade, after trying various sizes from i to
3*5 mm., at Madras a 2 mm. blade is used for all cases, a difficulty being
found with any smaller opening in introducing an iris forceps to deal
with an iris impacted in the wound, should this complication occur.
Otherwise Elliot® recommends a trephine with a diameter of 1*5 mm.
as the most useful size. Before replacing the flap, the eye should be
inspected, to make sure that the pupil is central in position, and that
no tags of iris are caught in the trephine hole.

Immediately after operation no drops are used, but on the third day
atropine is inserted. The reason for this practice is to guard against
iritis, the one complication which is to be feared.

A recent paper by Stephenson^ deals with some of the causes of
failure after Elliot’s sclero -corneal trephining. Septic infection is, of
course, a danger common to all operations ; but it is possible that some
cases of late infection after trephining are due to the continued existence
of a filtering cicatrix. Intra-ocular haemorrhage, again, is a danger
common to all operations for glaucoma, but seems less likely to occur
during trephining than in any other of the operation^ commonly prac-
tised. According to Elliot, this is one of its advantages. Mechanical
blocking of the trephine hole by iris, ciliary body, lens capsule, or lens
itself, is undoubtedly the most frequent source of failure. The number
of cases in which it occurs probably varies inversely with the expertness
of the operating surgeon.

References. — ‘^XVIIth Internat. Congr. Med. 1913, Sect, ix, I, 57 ;
^Ophthalmoscope, 1913, 324; Hbid. 328; Hhid. 640.

GOITRE, ENDEMIC. Herhert French, M.D., F.R.C.P.

Etiology. — ^New light is being thrown upon the causation of endemic
goitre and cretinism. The fact that both are specially related to
districts where there are limestone-rock formations remains, but there
is a growing doubt as to drinking wnter being itself the causal factor.
It is not the drinking water, nor any of its purely chemical ingredients,
that produce the thyroid gland lesion, but the presence in the water

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of certain micro-organisms which seem to flourish better in limestone
waters than in others, Nor do the bacteria occur in the water only ;
they are present in the soil as well ; indeed, it appears likely that this
is their primary source, and that they pass thence to the water and so
to the persons who become affected. Adolf Kutschera^ investigated
the question fully in a goitrous district of the Austrian Alps. The
distribution of the cases showed that the water supply was not a
common factor, and yet that the cause was related to particular
residence-places and their immediate neighbourhood.

That water can carry the infective agent under certain circumstances
is, however, established ; and the researches of McCarrison® in the
Western Himalayan districts of Chitral and Gilgit, where goitre is
endemic, common, and severe, show that a micro-organism is at the
root of the mischief ; that this micro-organism may reach man either
direct from the soil, or indirectly by the vehicle of drinking-water ;
that it produces the goitre-forming toxins in the alimentary canal ;
that similar goitrous changes are produced experimentally in animals
when bacteria are employed for the purpose ; and that human beings
suffering from these goitres are relieved, in some cases rapidly, by the
use of a vaccine prepared from cultures of the bacilli.

It appears probable that goitrous enlargement of the thyroid gland
may result, not from infection with one kind of micro-organism only,
but from the effects of different micro-organisms in different countries.
In support of this, McCarrison quotes the work of Carlos Chagas upon an
acute epidemic form of thyroid inflammation that affects children in
certain parts of Brazil; it has been termed ''parasitic thyroiditis,”
and it is due to a trypanosome, the Schizotrypanum possessing

peculiar features, and is conveyed from man to man by a biting insect,
the Conovrhinus megisius. According to Brumpt, other insects also
can act as hosts, especially the bed-bug [Ciniex lectularins) , the excreta
of which are highly infective. The malady, as the name implies, is
essentially an acute condition ; but if it does not terminate fatall}^
within fifteen to thirty days of its onset, it lapses into a chronic form of
illness, characterized by the presence of goitre, often of very large size,
and S3mptoms due to partial or complete loss of function of the
thyroid mechanism, nervous symptoms, and affections of the heart.
It is not possible to distinguish such cases from cases of true " endemic
goitre” hy blood examination, since the trypanosome, ’ which is said
to cause the goitre, disappears from the blood-stream after the acute
symptoms have subsided.

When, as in Gilgit, the endemic goitres are due to infection from the
soil, by a micro-organism, directly or indirectly, the way is opened up
towards the adoption of preventive measures. From McCarrison's
very careful work we know enough to make it certain that good sanita-
tion, cleanly houses, cleanly food, and the provision of water-supplies
which are not fouled by the excreta of man and beast, are measures
which promise an extermination of the disease.

Dieterle, Hirschfeld, and Klinger® show that goitre is due to residence

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in a particular district, and not to drinking its water, and their findings
support McCarrison's theory of bacterial infection of the soil. Using
rats as the experimental animals, they found that they developed goitre
when they were kept in a goitrous district, and this no matter whether
the water they were given w-as fresh or thoroughly boiled ; similar
rats kept in non-goitrous districts but given boiled water from goitre
districts to drink did not develop goitre ; other rats kept in the goitre
districts, but given water from non-goitre districts, became goitrous.
They conclude, thereforej that it is not the water, but something else
(e.g., soil infection) in the affected regions, that causes the inhabitants
to be goitrous.

Howle*^ draws attention to the fact that there are parts of Australia
in which goitre is endemic. He has investigated the drinking-water
from the creeks in one district, and the faeces of both goitrous and of
normal persons in the same district, and his results, so far as they go,
entirely confirm McCarrison’s discovery that the goitres are due to
ingested micro-organisms. He did not employ vaccines in treatment,
but the best results were obtained in many cases from the use of
intestinal antiseptics. He used in particular Thymol i gr. to 3 gr.
thrice daily in cachet or mixture, and Urotropin 3 to 10 gr. thrice daily
in powder form.

Symptoms. — Bauer® finds that a very large proportion of patients
suffering from simple goitre have some functional disorder of the heart,
generally taking the form of an accidental systolic bruit in the
pulmonary area, or local to the cardiac impulse ; accentuation of the
pulmonary second sound ; and slight increase of the cardiac dullness
to the left. The impulse is not displaced or increased in force, the
pulse-rate is not accelerated, and as a rule the patient has no
subjective or objective symptoms to call attention to the heart.

References. — ^Munch. med. Woch. 1913. 393 ; ^Lancet, 1913, i, 147, 219,
and 365 ; ^Munch. med. Woch. 1913, 1813 ; ^Austral. Med. Gas. 1913, 327 ;
*Deut. med. Woch, 1912, 1966.

GOITRE, EXOPHTHALMIC. (See also Thyroid, Surgery of.)

Herbert French, M.D., F.R.C.P.

Etiology. — ^Mori^ records three very instructive cases in which
symptoms of Graves’ disease developed in consequence of secondary
metastatic growths in the th5n:oid. In one the primary growth
was a sarcoma of the pelvis ; in the second, a melanotic sarcoma
of the eye ; and the third, a carcinoma of the breast. In all three the
size of the secondary deposits in the thyroid gland was relatively small,
and there were no papillary proliferations of the surrounding epithelial
cells which are characteristic of ordinary cases of Graves’ disease.
Exactly how the symptoms resulted from the metastatic growths in
the thyroid gland it is difficult to say, but the author’s view was that
the secretion of the follicles that were becoming compressed by the
metastases escaped into the circulation in more than normal quantities,
and so produced th;5'Totoxic symptoms.

Symptoms. — There is a tendency to be afraid of diagnosing Graves’

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disease when there is no exophthalmos ; yet the latter symptom is very
often absent. ]\IcKisack^ records twent^^-one cases, in all of which
there was persistent tachycardia ; in most, there was fine tremor of
the hands ; in many, slight, not obtrusive, but definite enlargement
of the thyroid gland ; in none, exophthalmos ; all but three were
women.

Treatment. — Musser® wonders whether the benefits that may some-
times follow operative treatment of exophthalmic goitre are to be
attributed essentially to the gland excision, or whether they may not,
in part at least, be due to the fact that an operation has been done ; he
believes that almost any violence to the s^^steni may be followed by
temporary or even permanent cure, and quotes cases in which Gra\^es’
disease, previously very severe, subsided after such serious intercurrent
accidents as acute appendicitis or enucleation of the eye after trauma.
He holds that many physicians omit to pay sufficient attention to all
sorts of little details that may need careful supervision if the general
health of their exophthalmic goitre cases is to be raised to its best —
details which vary greatly according to the merits of different cases.
He concludes that “surgical intervention should not be ad^dsed in cases
of goitre associated with functional or organic disturbances of other
secretory organs, until the associated disorders are removed or relieved.
If relapse occurs in spite of general treatment, or in spite of treatment
directed against the disorders of other organs, a goitre should then be
treated surgically. IMedical treatment should be continued from six to
bventy-four months. Favourable results should not be promised
unless the patient is under the absolute control of a physician, so that
treatment by rest, diet, bathing, physical therapy, and so forth, may be
carried out with precision and continuity. Surgical intervention
requires the same rigid and prolonged after-treatment to give perma-
nent results.”

Schlesinger-^ adds his experiences to the question of whether cases of
Graves’ disease should be treated by operation or not. His views are
based on twenty carefully watched cases. There was no death from
the operation ; improvement resulted in many, but cure was effected
in three only, Schlesinger is in favour of the operation of removing
half the gland only, and ligaturing the superior thyroid artery on the
other side. In regard to the indications, he ad\''Ocates doing it w’hen
the patient, ha\dng had two months’ careful medical treatment, has
not already begun to show definite signs of relief.

Cohen ^ speaks strongly against the hasty or routine adoption of
surgical treatment of exophthalmic goitre, and lays particular stress
upon the fact that a very large number of cases recover without any
special method of mechanical or personal treatment, even without
prolonged rest, but especially if the patient can be kept at rest, with
regulation of diet and under proper hygienic surroundings, for a suffi-
cient time. He acknowledges that operation is sometimes, though not
frequently, indicated ; the chief circumstances under which he would
advise it being : (i) When the disorder has persisted for a long time,

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and has advanced despite the best medicinal and. hygienic manage-
ment, including prolonged rest ; (2) When the disorder is progressive,
or far advanced, and is either disabling or dangerous, or threatens to
become so — even though no sufficient attempt has been made at
hygienic management, including rest ; (3) When the patient’s means
or social status is such that rest is impracticable, and the disorder,
although slight, is partially disabling, and has persisted for a year or
more under treatment, with no sign of yielding.

He estimates that at least 70 per cent of all cases recover either spon-
taneously or under non -surgical treatment. He also discusses the diffi-
culty of making any comparison between cases treated surgically and
those treated non-surgically, because there is no standard by which
one can determine what is meant by their recovery. Mere survival
after operation is not recovery ; and Cohen holds that Hale White is
right in saying that most patients are at least as likely to be able to
continue their ordinary duties in life with non-surgical as with surgical
treatment. He devotes a large part of his paper to details of the
therapeutic measures that may be adopted, including Rest; Out-
door Air ; Underdone Meat ; an abundance of Hot Water to drink ;
the limitation of carbohydrates ; the use of Baths ; Massage and
manipulations ; preparations of the Ductless Glands, particularly those
derived from the thymus gland, the adrenal capsules, and the pituitary
body ; intestinal antiseptics, and drugs required for symptomatic
treatment, amongst which he advocates particularly Strontium
Bromide, Ergot, and Picrotoxih. He has found the various sera, anti-
thyroidin and thyxoidectin, disappointing in practice. The original
paper should be consulted for a large amount of detail and for thera-
peutic suggestions.

The value of Calcium Lactate in controlling the paroxysms of tetany
after thyroidectomy is recorded by Shepherd.® In one very severe case,
after all other treatment, including the giving of parathyroid, failed,
60 gr. of calcium lactate were given every four hours, and after five
doses the relief was remarkable. The patient disliked the medicine so
much that it was discontinued, but she took it again when the
paroxysms recurred, and again there was remarkable and rapid relief.
Apparentl}^ it has to be continued, but there seems to be little doubt
as to its real value.

References. — Frank/. Zeits. / Pathol. 1913, xii, 2; ^ Brit. Med. Jour.
1913, i, 20S ; ^Amer. Jour. Med. Sci. 1912, i, 810; ^Berl. hlin. Woch. 1913,
57; °Amey. Jour. Med. Sci. 1912, ii, 13 ; ^Ann. Surg. 1912, ii, 663.

GONORRH(EA. C. F. Marshall M.D.

Diagnosis. — Schwartz and McNeil^ report further experiences
with the complement fixation test in the diagnosis of gonococcus infec-
tions of the genito-urinary tract. (See Medical Annual, 1912, p. 304)
A polyvalent antigen is used, because of the wide divergence between
different strains of gonococci. It is prepared by growing several
strains on salt-free veal agar, neutral in reaction to phenolphthalein ;
twent^'-four hour cultures are washed off the agar slants with distilled

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water, and the resulting suspension is heated for two' hours in a water-
bath at 56° C. It is then centrifugalized and passed through a
Berkefeld filter. \Vhen the antigen is used, one part of 9 per cent
saline solution is added to nine parts of antigen to make it 0*9 per cent
saline.

The authors’ conclusions are as follows : (i) The test is absolutely
specific, and a positive reaction signifies the presence or recent activity
of a focus of living gonococci. (2) A negative reaction does not exclude
it, but is of considerable diagnostic importance. (3) A strong positive
reaction does not occur before the fourth week, and only then in very
acute cases with some complication. (4) No reaction is obtained if
the disease is limited to the anterior urethra. (5) A positive reaction
does not disappear till seven or eight weeks after cure, owing to the
persistence of antibodies in the blood ; therefore, if it is obtained
seven or eight weeks after apparent clinical cure, the patient must be
regarded as still harbouring gonococci. (6) The technique of com-
plement fixation is simpler than that of isolation of the gonococcus
in culture, and has less possibilities of error. (7) In cases regarded
clinically as post-gonorrhoeal a positive reaction is obtained in 31 per
cent. (8) In 62 cases of chronic prostatitis of less than three years’
duration, the reaction was positive in 54 per cent. (9) In 165 cases
regarded as clinically cured, the reaction was positive in 13 per cent.

(10) In women, the reaction is positive only when the cervix is involved.

(11) The complement fixation test is useful in gynaecology owing to
the uncertainty of bacteriological diagnosis. (12) The test is of value
in the diagnosis between gonococcal and other forms of arthritis.
Three cases of gout gave a negative reaction, although one patient
had had gonorrhoea four times. A case of syphilitic arthritis gave a
negative gonococcus reaction but a positive Wassermann. Another
case of S5rphilitic arthritis had gonorrhoea four times, the last one
thirteen months previously ; but the test was negative and the Wasser-
mann positive. Nega'tive reactions were also obtained in strepto-
coccus and tuberculous arthritis and in arthritis deformans. Three
cases with Clinical symptoms of acute rheumatic fever gave a positive
reaction, but in these there were other signs of gonorrhoea, and the
gonococcus was present in tv^o. These cases show that the test does
not exclude the presence of some other concomitant infection. (13)
The test is of no value in the differen-tial diagnosis of arthritic cases
which have recently been treated with gonococcus vaccine.

Comparing the gonococcus complement fixation test with the
Wassermann reaction for syphilis, the authors point out that in the
former there is a true antigen-antibody combination, as the antigen
is prepared from the specific organism, while in the Wassermann
reaction there is no true antigen-antibody combination. The so-
called antigens in the latter reaction are present in the lipoidal
substances of the tissues, whether syphilitic or not. Again, a negative
reaction in the test for gonococci is of more value than in the Wasser-
mann reaction, for in the latter case the reaction may be negative

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owing to recent mercurial treatment, or owing to the enclosure of
spirochastes by a connective-tissue capsule which hinders the absorption
of toxins and the consequent formation of antibodies.

Comparing the relative diagnostic value of complement fixation
and bacteriological methods, the authors remark that bacteriological
proof of the presence of the gonococcus is difficult to obtain. A Gram
stain properly made can be accepted when the gonococci are abundant,
but not in chronic cases with few organisms present. The sources of
error include M. catavvhalis, degeneration forms of Gram-positive cocci
which do not retain the Gram stain. Trichomonas vaginalis, and aberrant
forms of B. coli. Hence, bacteriological diagnosis depends on culture,
the technique of which is more difficult than that of the complement
fixation test. The gonococcus grows only in special media, and culture
may fail owing to the presence of other rapidly-growing organisms
which inhibit its growth or render its isolation impossible. This
applies especially to women. They conclude that the complement
fixation test gives better results than those of bacteriological diagnosis,
except when the gonococcus is isolated in pure culture. They also
point out that the absence of a positive reaction in the early stages
of infection is useful in differentiating between a fresh infection and
the recurrence of an old one, and that this may be valuable in medico-
legal problems.

Schwartz and IMcNeil’s re-sults have been corroborated by several
other observers.

Gardner and Clowes- have also tested cases in which both gonorrhoea
and syphilis were present. They find that the complement deviation
test for gonorrhoea, when carried out with a polyvalent antigen,
permits of specific differentiation even in the presence of syphilis and
other diseases which cause complement deviation. Cases with a
strong Wassermann reaction for syphilis generally gave a negative
gonococcal reaction, and the exceptions showed evidence of concomitant
gonorrhoea.

Pedersen* mentions that 3 /. catarvhalis is in its early cultures Gram-
positive, and in later cultures Gram-negative. Hence, as it is morpho-
logically similar to the gonococcus, the only means of differentiation
is by culture. He also mentions that bacteriologists have found at
least twelve different strains of the gonococcus, with different degrees
of virulence, and that this accounts for the wide divergence in the
incubation, course, and complications of different cases.

Treatment. — Pedersen^ recommends either of the following methods
for abortive treatment of gonorrhoea in the male : (i) Swabbing out the
first inch of the urethra with 3 to 5 per cent Silver Nitrate solution
through a short urethroscopic tube ; (2) Irrigation of the first three
inches of the urethra by a small catheter and hand syringe with any
mild antiseptic ; (3) Instillation of any of the newer silver salts in
strong solution by means of a drop-bottle, retaining the solution for
ten to twenty minutes, and repeating the application twice or thrice
daily for three days. The penile ui'ethra should be closed beyond the

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desired spot by a clip or elastic band. The foreskin and glans must
also be disinfected, to prevent auto-infection of the urethra. He
remarks that very few patients come early enough for abortive
treatment to be successful, and that statistics of success cannot be
complete unless they rest on smear and culture diagnosis, and distin-
guish the desquamative or prepurulent stage when gonococci are
present in epithelial cells, without pus.

In acute anterior gonorrhoeal urethritis the treatment may be expectant
or by irrigation, Pedersen limits irrigation treatment to cases of
anterior urethritis with no congestion of the prostate appreciable to
rectal examination. He uses Chetwood's double -current apparatus
with a large vessel never higher . than the' patient’s ear, thus giving
pressure equal to that of the urine during micturition. In expectant
treatment the urine is diluted and neutralized b^^^ Potash, Soda, or
Lithia, to render it less irritant. The precipitation of crystals, such
as sodium urate, should be avoided, as they cause irritation. The
tendency to chordee is diminished by small doses of Aconite every one
or two hours during the day.

In acute posterior urethritis, which occurs in greater or less degree
in the majority of cases, irrigation should be avoided, because hydraulic
pressure may damage the delicate structures in the posterior urethra
and favour penetration of the infection. Expectant treatment should,
therefore, be adopted till the acute s;^unptoms have subsided. Severe
cases require rest in bed, with hot or cold applications to the perineum,
or rectal irrigations. Autogenous Vaccines may also be used. Posterior
urethritis which persists requires irrigation. The best method is by
a small catheter passed into the bladder, after urination. The bladder
is then irrigated to prevent infection, filled with boric acid lotion, and
afterwards with Silver Nitrate (1-20,000 to 1-5000) or Potassium
Permanganate (1—10,000 to 1-4000). The patient then evacuates the
bladder. Urinary antiseptics should also be administered before and
during irrigation. Another good method of irrigation is by a small
catheter and hand syringe, b}^ which pressure can be carefully regulated.
Heat to tolerance is essential in these manipulations. Opium may
be given if necessary. Pedersen does not believe in irrigation of the
deep urethra under high pressure from the meatus, because it may lead
to complications.

In chronic gonorrhwal urethritis Pedersen advocates Buerger’s
Urethroscope, a modification of Goldschmidt’s. This has, like the
other, a lateral instead of a terminal opening, but smaller, so as
to prevent undue prolapse of mucous membrane into it. The system
of lenses magnifies about five diameters, and the instrument has
curved and straight ends which are interchangeable. Pedersen prefers
the latter, by wliich the whole urethra can be examined, from the
neck of the bladder to the meatus. He is of opinion that no case
of gonorrhoea should be discharged as cured till after this examination.
By this means thickening, granulations, and papillomata of the mucous
membrane can be recognized and treated through the urethroscopic
tube with the electric cautery or chemical caustics.

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Harrison and Houghton® report on the use of Heated Sounds in
gonorrhoea. This method, introduced by Valentine, is based on the
fact that the gonococcus is destroyed by exposure for six hours to a
temperature of 104° F., and that when patients with gonorrhoea
contract a fever with high temperature, the discharge ceases for the
time. The apparatus used consists of a double silver catheter. The
outer tube is closed at the vesical end, and is provided with an outlet
for the injected water. The inner tube is connected with an irrigator
by means of a rubber tube with a clip. The method of procedure is as
follows : A suppository of -V grain atropine is inserted the night before,
and the morning of operation. The urethra is now irrigated in the
usual way. The patient then lies on a couch, and the instrument is
introduced as far as the bladder. The irrigator is placed 18 in. above
the couch and is filled with water at 114° F. The water is allowed
to run through the apparatus, and the temperature, is gradually
increased up to 125° F. This is continued for thirty minutes. A
higher temperature may cause blistering of the meatus.

Treatment on the same principle may be applied by means of
Kobelt’s Electrically - heated Bougies. These are gum -elastic or
metal bougies heated by an electric resistance coil enclosed within
them. In the circuit between the bougie and the source of electricity
is another resistance coil, in which is inserted the bulb of a thermometer
which records the temperature. The source of electricity is either an
accumulator, or the main supply converted. The patient is prepared
with atropine, and the urethra irrigated as above. The current is then
turned on, and the temperature regulated through the resistance at the
electrical source. The temperature may be raised to 150° F., and
maintained for fifteen minutes without damage to the tissues. With
either form of apparatus the best results have followed the application
of the bougie two or three times a week. The results are said to be
good in acute, subacute, and chronic cases of gonorrhoea. In 1 1 acute
cases the gonococci disappeared after the fifth day. As regards
complications, 2 cases of mild epididymitis occurred out of 35.
Harrison suggests that this method may act like Bier’s congestive
treatment, as w^ell as by direct action on the gonococci.

Discussing the subject of gonorrhoeal arthritis and its treatment,
Dardel® says that benefit is sometimes derived from Salicylate of
Sodium and Aspirin in acute cases, and that the axiom that salicylate
of sodium differentiates between ordinary and gonorrhoeal rheumatism
must not be construed literally. If these fail. Antipyrin, Pyramidon,
or Quinine may be tried. However, such treatment is symptomatic,
and does not influence the cause of the disease. Local treatment
includes Puncture of the joint if there is much distention, Passive
Movement and Massage when the acute symptoms have subsided, and
Arthrotomy in suppurati\'e cases. More recent treatment comprises
gonococcal Vaccines, by Rogers’s antigonococcic or by antimeningo-
coccic Serum, Badiotherapy by means of exposure to radium, radio-
active mud or injection of radium salts into the joint, Bier’s method

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of Passive Hyperaemia, and Themotherapy. The author prefers the
last method, either by douches or by placing the joint in a hot-air box.
The temperature in the latter may be raised to 175° or 210° F. for
half an hour at a time. Hot-air treatment is easier to apply by means
of electrically-heated apparatus. -Good results are also obtained by
Hydrotherapy, in the form of hot-Avater or hot -vapour douche. At
Aix-les-Bains the natural mineral sulphur water is applied as a local
douche at a temperature of 105°-! 10° F. for ten to fifteen minutes, and
followed by passive movement and massage. In the vapour bath the
limb is immersed in the atomized hot w^ater for about twenty minutes,
after which passive movement and massage are performed. This is
indicated in partly ankylosed joints, but not in acute cases. In chronic
gonorrhoeal arthritis, in addition to the above methods, the urethra
requires disinfection, as many obstinate cases depend on chronic
urethro-prostatitis. Some authors have reported improvement after
Thyroid treatment, 2 to 6 grains daily.

Vaccines. — Guerchoune and Finnkelchteinne" report good results
in acute and subacute gonorrhoeal urethritis, as well as in arthritis and
epidid3nnitis. The gonococci disappeared in 10 out of 27 cases of
acute and subacute urethritis. The authors used a polyvalent hetero-
genous vaccine made from cultures of gonococci on agar mixed with
water or blood. The dose for the first injection was 2 million cocci,
and this was doubled at each injection, the maximum being 50 million.
The authors advise the use of two vaccines, one containing small doses
and the other large. Injections were made subcutaneously into the
arm or the abdominal wall every six or seven days. No other treat-
ment was given, so as to determine the effect of the vaccine, but the
authors recommend its combination with the other measures usually
adopted. The vaccine reaches gonococci which have penetrated
deeply or become generalized, and its action is probably due to the
formation of antibodies.

Erlacher ® also, has found vaccine treatment successful in acute and
chronic gonorrhoeal urethritis. He begins with a dose of 5 million
cocci given every four days, increased in some cases up to 28 million.
Local treatment is given at the same time. He concludes that
vaccines are a useful addition to the treatment of acute and chronic
gonorrhceal urethritis, both on account of their curative action and
also their diagnostic value as regards a cure, for vaccine treatment will
produce a gonococcal discharge in cases apparently cured by local
silver treatment. In Erlacher’s cases there was a general reaction
in exacerbation of symptoms, but no local reaction at the point of
puncture.

Pedersen® also recommends vaccines in acute posterior urethritis,
preferably autogenous, owing to the variations in the different
strains of a stock vaccine. He prefers large doses to small. In one
successful case of double chronic relapsing seminal vesiculitis, he
gave 400 million cocci eveiy^ other day, three times a week, and finally
once a week.

CaONORRHCEA

270

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B. Hughes^^ considers that chronic gonorrhoeal arthritis is due to
mixed infection by gonococci and staphylococci. He therefore
recommends a mixed vaccine of gonococci and staphylococci, beginning
with 100 million of the former and 150 million of the latter, increased
to 500 million and 1000 million respectiv^ely. After the second dose,
joint adhesions are broken down under an anaesthetic, followed by
massage and dailj’’ movements during the vaccine treatment. Auto-
genous vaccines are best. If there is chronic gleet, the penis should
be massaged over a stout metal bougie, followed by a Protargol Bougie,
Copaiba should be given intemalhL

Ribollet^^ thinks that Balsams are contraindicated in the early
stages of gonorrhoea, that they increase the duration of the disease,
and often favour complications. He points out that the balsams have
no bactericidal action on the gonococcus, and only diminish pain and
suppuration. But suppression of suppuration in acute gonorrhoea
counteracts the natural means of defence by phagocytosis and leaves
the gonococci free to penetrate the mucous membrane. Balsams
should, therefore, be limited to the later stage of gonorrhoea, when
the gonococci have mostly disappeared, and should be given in large
doses.

Harrison^^ recommends Agar Jelly Bougies in subacute and chronic
cases of gonorrhoea. They are made of 40 parts of 2*5 per cent agar
jelly melted and added to 160 parts distilled water. When cold, this
is rubbed up with i part of Protargol. By this means the drug is kept
longer in contact with the mucous membrane.

References. — ’^Amev. Jour. Med. Set. 1912, ii, 369, S15 ; -AM'. Med.
Jour. 1912, ii, 734 ; 1913. i, 327 ; ^Ibid, 1913. i, 327, and 1912, ii, 779 ;

'^Jour. R.A.M.C. 1913, 135; Manual of Venereal Dis. 1913, 24S ; ^Med.
Rec. 1913, i, 150; '^Vratch. Gas. 1912 {Ann. des Mai. Ven. 1913, 205);
^Deut. med. Woch. 1913. i 113 ; Med. Jour. 1913, i, 327 ; Med.

Jour. 1913, i, 1268; ^^Ann. des JMal. Vhi. 1912, Dec.; ^“Jour. R.A.M.C.
1912, Oct.

GOUT, Herbert French, M.D., F^.R.C.P.

Treatment. — The fact that opinions differ so widely, is an indication
that no absolute rules as to Dietary can be laid down, and this is the
view held by Garrod.^ He maintains that in food there are potent
substances which are essential to normal metabolism, though negligible
from a calorie-producing point of view ; and that more knowledge is
needed before we can possibly lay dowm rules of dietary on scientific
lines. Most theoretical diet tables for gouty subjects have been drawn
up by those whose minds were at the time occupied with one
particular scientific fact, to the exclusion of others which are often
of still greater importance in practice ; and the results have not been
as beneficial to patients as was hoped. The main thing for a gouty
subject is to be moderate in all things, and to take simple rather
than complex foods. In special cases, extreme dietaries may be of
use as temporary expedients, such as one which aims at the exclusion
of all purin substances ; but Garrod is convinced that no diet which

NKW TREATME.V'i' ORAIMULOMA, PUDENDAL

excludes altogether one or more of the main ingredients of human
food, or even a minor constituent such as the purins, can be regarded
as a desirable one over long periods. It is less a matter of what one
eats than of how much one eats, and when and how. Garrod doubts
whether by strictly dieting a gouty patient as much is achieved as w'e
think. It must be confessed that among hospital patients who could
not, if they would, follow out any strict rules of dietary, who seldom
pay heed to our advice that they should give up beer, and who, as soon
as an acute attack is over, revert to their previous habits of life, the
course of gout does not seem to differ materially, as regards the charac-
ter, frequency, and severity of the attacks, from that followed in people
who are able to adjust their living according to the best advice to be
obtained.

Errors of diet are not the only factors at work in the causation of gout,
and regulation of food is only one of the means available for its control.
Temperance in all things, and not in eating and drinking alone, is the
golden rule for the avoidance of this disease and its manifestations.
Amongst the well-to-do, Golf is probably more important than a purin-
free dietary in this respect.

The value of Atophan in the treatment of acute and subacute gout
is spoken well of both by Kahlo*^ and Brugsch.^ The drug has apparently
a definite chemical formulary, consisting as to two parts of phenyl-
chinolin and as to four parts of carboxylic acid. It is dispensed as a
rule in tablets, each containing 7J gr. of the drug ; these disintegrate
readily in water, though they are insoluble. Kahlo prescribes one after
each meal and at bedtime, but in severe cases increases the total dose
per diem up to as much as 60 gr. The only ill-effects noticed were a
certain amount of upset of the stomach ; the acute gout was relieved
speedily, the temperature, pain, and swelling lessening within a very
few hours, and almost all the acute symptoms subsiding within from
twenty-four to forty-eight hours. A large majority of his cases had
been treated previously by colchicum, salicylates, aspirin, etc., and
almost without exception, they stated that the relief obtained from
atophan was greater than that received from remedies previously
employed. Burgsch also speaks well of a preparation discovered by
Prof. Wolff en stein in - the treatment of acute gout ; it has a very
complex formula, expressed by the name acetyl-aceto-salicyl-trichlor-
isobutyl-ester.

References. — ^Lancet, 1913, i, 1790 ; -They, Gaz. 1912, S42 ; ^BevL
Woch, igi2, 1597.

GRANULOMA, PUDENDAL. Leonard Rogers, M,D., F,R.C.P.

J. Grindon^ reports three cases from St. Louis. He failed to find the
protozoa-like parasites described by Donovan and Carter in India.
His cases were all in negroes ; but no history of contagion could be
obtained. Spirochaetes may also be absent.

Reference. — ^Jour, Cutan, Dts. 1913, 236.

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MEDICAL ANNUAL

HEMORRHAGES IN THE NEWLY-BORN.

Frederick Langmead, M.D., F.R.C.P.

J. E. Welch^ gives a lucid description of this important but, fortu-
nately, rare disease. The baby may be in every way apparently
healthy before the bleeding begins. Then, without warning, it may
vomit a quantity of fresh blood or pass bloody or tarry motions, and
these may be the only signs of haemorrhage. The bleeding may be
subcutaneous, causing either petechiae or haematomata ; or the
umbilicus, a divided prepuce, or the gums may be the site of haemor-
rhage. Fatal internal haemorrhages not infrequently occur without
external manifestations, and may affect the brain or any of the thoracic
or abdominal organs. Jaundice may develop. On the other hand,
the baby may merely become pale and feeble, and die without apparent
cause, the diagnosis being made only at the autopsy. Then haemor-
rhages are found usually within the serous cavities, like that of the
peritoneum, or beneath a serous membrane, such as the pleura, the
pericardium, or the capsules of the liver or kidney. Microscopical
examination of the various organs shows anaemia, and cloudy swelling
of the epithelium of the parench3niiatous organs, whilst the epithelium
of the gastro-intestinal tract usually gives evidence of the most advanced
degeneration and desquamation.

Etiology. — ^Welch believes that the endothelial cells of the blood-
vessels are at fault, and that a disturbance in the balance of the
ferments of the cells is the immediate cause of the haemorrhages. This
disturbance is due to malnutrition caused in various ways, especially
by auto-intoxication due to excessive growth of bacteria in the
intestinal tract. He disagrees with the view, held by many, that the
disease is due to deficient coagulability of the blood, since in some there
is no lack of coagulability, and moreover, successful treatment by
seriim does not promote local coagulation at the sites of the bleeding.
The cure is brought about in some way other than by increasing
coagulability — in his opinion, by improving the nutrition of the
endothelial cells.

Treatment. — However divergent opinions may be as to the cause,
there seems little doubt that the treatment advocated by Welch, of
injecting with Human Serum, is attended by . a large measure of
success, and that now there is a fair hope of recovery, whereas a few
years ago the condition was regarded as practically fatal. This author
himself records three more successful cases, making thirty-five in his
own practice. He states that there is no danger of anaphylaxis such
as occurs if the serum of other animals is used. Transfusion may
cause haemolysis, thrombosis, or embolism, and should be reserved for
those cases where prolonged haemorrhage has led to great reduction
in the number of the blood-cells.

Le Grand Kerr-, advocates the use of Local Measures to arrest the
bleeding, no matter what internal remedies are used. Capillary oozing
may thus be controlled by a gauze pad saturated with a 10 per cent
solution of Gelatin, a 2 per cent solution of Galcium Chloride, or a

NEW TREATMENT 273 H/EMORRHAQES IN NEW-BORN

I -1000 solution of Adpenalin. Prolonged but gentle pressure and
the actual cautery also have their place as local agents. Therapeutic
efficiency, however, demands something more than a control of local
haemorrhage. He believes that, apart from hemophilia, haemorrhagic
affections of children are due largely to toxic substances which find
their way into the circulation, and that these agents act not only upon
the nervous system, but in a direct manner upon the endothelial lining
of the smaller blood-vessels, there producing degenerative changes.
Thus far he agrees with Welch, but differs in regarding impaired
coagulability of the blood as the one feature which is always prominent.
The primary objects in the treatment of this affection are (i) To combat
the toxic elements which change the character of the blood ; (2) To
limit their effect on the blood-vessels ; and (3) To improve the coagu-
lability of the blood. The last admits of no delay, and in most instances
is urgent. He advocates the introduction of Saline Solution, when the
haemorrhage has been prolonged or severe enough to demand partial
restoration of the volume of the blood ; but points out that we should
strive to produce a blood which coagulates readil}", and that the indis-
criminate use of salines may do positive harm by diluting the agents
in the blood which make for coagulation. The chief aim of treatment
is to suppty as quickly and as safely as possible the main elements in
which the blood is lacking or which have become inefficient, and while
thus controlling immediate consequences, to give the blood-making
organs a chance to restore the normal balance. To accomplish this,
he, like Welch, recommends Blood Serum and Whole Blood, and prefers
human serum to that of other animals. In his opinion, transfusion is
the ideal method. When transfusion is impracticable, 5 or 10 c.c. of
whole blood may be withdrawn from a near blood relation and injected
immediately into the child subcutaneously. This is particularly
applicable to urgent cases, whilst human blood serum is indicated
in the less urgent ones. Both should be obtained from a near blood
relation. Other details which should not be neglected are, absolute
rest of mind and body, adequate hygienic care, a harmless but sufficient
diet, and the treatment of the underlying condition if it is discovered.

V. M. Reichard^ and W. B. Jennings^ each report a case of melasna
neonatorum which recovered after the injection subcutaneously of
Normal Horse Serum. It is interesting to note that in the case recorded
by Jennings, subnormal temperature and urticarial rash were noted
during the treatment, and may in all probability be ascribed to
anaphylaxis.

R. Franz® has treated five cases with Blood obtained from umbilical
cords at the birth of normal children. All recovered, the last four
rapidly. He collected the blood in sterile flasks, centrifugalized it,
and injected it at body-temperature, sometimes as long as four months
after it had been obtained. No untoward results followed.

References — '‘•iV.y. Med. Jour, 1913, i, 125; ^Amer, Med, 1913, j,
396 ; ^Jour, Amer. Med. Assoc . X912, ii, 1539 ; ^Ihid. 1913, U ii54 > ^ Munch .
med. Woch, 1912, 2905.

HAIR AND NAILS

274

MEDICAL ANNUAL

HAIR AND NAILS, FAMILIAL DYSTROPHY OP.

E. Graham Little, M,D., F.R.C.P.

Eisenstaedt^ reports a family affected with this curious disorder.
The author unfortunately can give only the affected members in the
earlier generations, and the pedigree suffers in exactness for this reason,
but it is sufficiently remarkable notwithstanding. Here is the
pedigree.

The members affected in each generation are indicated by the
darkened symbol. The author says that probably some of the collateral
members were affected, but no data of these could be obtained. One
of the children of the 5th generation is described in detail, and the
description is said to apply to the other two. There was no mental
deficiency in any of the three children, whose ages were respectively
14, 9, I. The thyroid gland, which has been reported absent in a
previous series of cases, was defective in one patient, aged 9, and normal
in the other, aged 14. The mother, a French Canadian by birth, died
of malignant abdominal disease.

The following are details of the oldest of the three children affected: —

“ The scalp is negative, showing no seborrhoea or parasites. The
hair-line begins 5*5 cm. from the bridge of the nose. The scalp is
covered wdth a moderate growth of pale dowmy hairs, none of which
is over 2 or 2 J inches in length, in spite of the fact that the patient has
not had his hair cut for many months. The hair grows very slowdy.
The ends are pointed, and none is split or broken off. They are very
easily removed and do not break on traction. There seems to be some
anomaly in their implantation. Here and there at wide intervals are
seen normall}?’ implanted coarser brown hairs. Microscopic examina-
tions of the hairs found nothing abnormal. No bacteriological
examination was undertaken. The eyebrows are very poorly developed.
There are no coarse hairs, and but a small number of lanugo hairs.
The eyelashes are extremely sparse and pale. Tliere is a plaque of
erythematous lupus on the nose and two symmetrical patches behind
the ears. These lesions have made their appearance within the last
year. On the right' cheek is a naevus flammeus of large size.’' — [The

PLATE XIX.

FAMILIAL DYSTROPHY OF HAIR AND NAILS

Case 1.

l''. ./ .-j '.4 L . iqi4

PLATE XX.

FAMILIAL DYSTROPHY OF HAIR AND NAILS

Case 2.

MEDICAL AXXD.IL, igi4

NEW TREATMENT

275

HEART, SYPHILIS OF

oth.er patients have not this condition. — E. G. L.]‘ '‘There is no
trace of axillary or pubic hair. The genitalia show no peculiarities
and no increase of adipose tissue in this region. In the axillary
region and on the anterior surfaces of the knees are sites of a papillary
hypertrophy of moderate degree. The hands are normal in contour
save for the distal phalanges, which are noticeably increased in
volume. The skin on the distal phalanges observed shows a moderate
increase in thickness. The nails on the hands are all affected to about
the same degree, and show an enormous hypertrophy of the nail-bed
Plates XIX and XX), The nails are kept short because, if allowed to
grow beyond a certain length, they become brittle, and crack at the
very slightest trauma. There is no marked accentuation of the striae,
either vertical or horizontal, though a slight increase can be ascertained.
Likewise there are no ulcerations about the base of the nail, and no
odour emanates from them. The nails of all toes of both feet are
affected in a similar manner but to a less degree. The feet are in other
respects normal. There is absolutely no sign of hereditary syphilis in
any of the children.”

Reference. — '^Jour. Amer. Med. Assoc. 1913, i, 27.

HEART AND AORTA, SYPHILIS OP.

Carey Coombs, M.D,, M,R,C,P.

Etiology. — Oberndorfer’s^ ample material at Munich shows an inci-
dence of syphilitic aortitis in nearly 7 per cent of all autopsies ; he
places it next to tuberculosis and malignant disease as a cause of
death. Two- thirds of the cases w’ere between 41 and 60 ; they
were fairly evenly dhdded as to sex. Deneke’s® Hamburg figures,
on the other hand, show a large preponderance of males, and include
one case of aortitis due to inherited s^^philis. This writer also
shows that heav}’ muscular -work plays no part in production of the
disease.

Recent work (see Aneurysm) has shown that aortic syphilis is an
active process and not merely a dystrophy ; this has a bearing on
treatment. It is equally important to realize, as Brooks® points
out, that coronar}’- disease accompanies aortitis in a majority of
cases, and that in over 80 per cent lesions of the myocardium are
discoverable. These may be found, containing spirochaetes, in the
secondary stages of the infection. There is therefore such a thing as
active syphilitic carditis ; and it is on this conception that our
clinical and therapeutic study of the disease must be based.

Symptoms. — ^These begin in some cases during the secondary stage ;
tach3xardia, extras^^stoles, and other forms of abnormal rhythm due
to local irritation of the myocardium, are described. Physical stress
is particularly likel}?- to excite them. Later there may be more definite
signs of focal m^^ocarditis ; of these, heart-block is the most note-
^vorth\^ though it is, of course, ver\" infrequent. Apart from these
evidences of focal disease, there are symptoms referable to diffuse
myocardial degeneration. The chief of these are dyspnoea on exertion.

HEART, SYPHILIS OF

276

MEDICAL ANNUAL

and pain in the prascordium, often anginal in character. Praecordial
tenderness and cyanosis are also common. To involvement of the
heart muscle must be attributed the notorious liability to sudden
death in these cases.

Apart from these evidences of myocardial disease, there are the
familiar symptoms of aortic regurgitation in a number of cases.
According to Longcope,^ syphilis is responsible for three-quarters of all
cases of aortic insufficiency in adults. [This figure is probably rather
high for Great Britain. — C. C-] Finally, there are the symptoms and
signs which arise directly from syphilitic infection of the wail of the
aorta ; this includes evidences of saccular aneurysm, and also those
of diffuse dilatation of the aorta. In this connection it should be
recollected that inequality of the radial pulses, so closely associated
with aortic an’eurysm, may occur in syphilitic aortitis apart from
the pressure of a sac. The writer has seen one example of this
in which ;i'-ray examination and the subsequent course proved the
absence of aneurysm ; and Laignel, Lavastine, and Vinhit,® who
report three cases in which the pulses felt unequal and gave
widel}^ different sphygmometric curves and sphygmomanometric
readings, were enabled in the same way to determine that there
was no aneurysm. The cause of the inequality seems to lie in
inflammatory obstruction or stenosis at the origins of the great
vessels ; at any rate, changes of this kind were noted in the only
autopsy which they performed.

Diagnosis. — The Wassermann reaction is recommended by several
writers. Oberndorfer says it is of fundamental importance, and since
its routine application to all cases of cardiac disease has been adopted
at his hospital, syphilitic aortitis has ceased to be a post-mortem-table
surprise ; and Deneke obtained a positive reaction in 86 per cent of
his cases, even in the days when the technique of the test was less
perfect than now. Longcope, Brooks, and Babcock® also insist on its
value ; the last-named says that the positive results are reliable, but
not the negative, while Brooks thinks it is the most definite sign avail-
able of late tertiary or quaternary syphilis, and specially important in
view of the large number of persons who make misleading statements
as to their venereal history.

Brooks further insists on the value of the response to antiluetic
treatment as a diagnostic aid, particularly in cases where the Wasser-
mann test and the patient’s history are alike indeterminate.

Apart from these indications, if the fact that syphilis not infre-
quently causes heart disease be borne in mind, fewer mistakes will be
made ; and the diagnostic value of collateral evidences of syphilis,
such as tabes, is alluded to by Deneke.

Prognosis. — Unfortunately,” says Deneke, ” most patients do not
come to the doctor till they experience pain and evidences of cardiac
inadequac}’.” This fact renders the average prognosis worse than it
v'ould be otherwise. He gives some very interesting figures showing
how bad the outlook is. Of 33 cases diagnosed at the beginning

NEW TREATMENT

277

HEART, SYPHILIS OF

of 1909 or earlier, 28, or 84 per cent, were knowTi to be dead by
November, 1912 ; at this same date 31 out of 47 diagnosed in 1910,
or 70 per cent, had succumbed ; while of the 60 seen in 1911, 53 per
cent had already terminated fatally. These fatal cases are examined
from the point of view of the relative fatalit}^ of each type of lesion.
Of those with signs of aortitis, but none of aneurj^sm or aortic
regurgitation, 33 per cent were dead ; of those with both aneurysm
and aortic regurgitation, 67*6 per cent ; of those with aneurysm
only, 64*3 per cent ; of those with valvular disease alone, 62*5 per cent.
The immediate cause of death in 74 fatal cases w^as rupture of aneur^^sm
in 9, angina in 5 ; sudden death occurred in no less than 33. In 7,
respiratory complications were responsible, and in 15, death was due
to some complication (once to sepsis following salvarsan, 7 times to
other syphilitic lesions). Deneke's figures also show that patients
thoroughly treated with antisyphilitic drugs live twice as long as
those less carefully handled.

Treatment — ^IVIany say that vigorous anti-syphilitic treatment wiU
bring about great improvement and even cure. Brooks is one of these.
He puts his patients to bed if their cardiac symptoms seem to demand
it, but not othervdse ,* and is guided by the same rule in regard to
cardiac tonics. He uses both Mercury and Salvarsan ; the former is
given by inunction, or hypodermically in the fonn of salicylate
dissolved in sterile albolene. After this has been carried on for a few
days at least, he begins salvarsan, his reason for using it being its
greater rapidity of action rather than any intrinsic superiority over
mercury. He gives it intravenously, and finds it much safer to divide
the dose of *6 gram into several injections ; to give the full dose at
one sitting is to incur grave risks, and he nearly lost three patients
through doing so. To these directly antispirochsetal drugs, Potassium
Iodide may be added, especially when the symptoms suggest the
presence of gross focal lesions in the myocardium.

There is some variance of opinion about salvarsan in cardiac syphilis.
Few observers seem to doubt its efficacy, but some speak strongly as to
its dangerous by-effects. Longcope thinks it should be given in
repeated doses ; Babcock says that if he gives it at all, he takes the
precaution of getting the patient to sign a paper declaring that the
risks of the treatment have been fully explained to him ! The general
opinion seems to be, however, that it should he withheld from
severe myocardial symptoms, at any rate till these have been
abated by rest and other measures ; that it should be given intra-
venously in small doses repeated at adequate intervals ; that mercury
should be given in conjunction with it ; that each dose may produce
immediate symptoms of an alarming character, which should be
provided for ; and that it is essential to follow up the treatment for a
long while.

References. — '^Munch. med. Woch. 1913, 505 ; med. Woch. 1913,

441; ^Amer. Jour. Med. Sci. 1913, iL 513; ^Arch. Int. Med. 1913, 14;
^Presse Mid. 1913, 607 ; ^Med, Rec. 1912, iL 684.

HEART DISEASES

278

MEDICAL ANNUAL

HEART, DISEASES OP. (See also Aneurysm ; Angina Pectoris ;

Auricular Fibrillation ; Auricular Flutter ; Ductus

Arteriosus, Persistent ; Heart and Aorta, Syphilis of ;

Heart-Block ; Pericarditis.)

Carey Coombs, M.D., JVLR.C.P.

Cardiac Efficiency in Schoolboys. — Mumford’s^ discussion of the
exercises for which the adolescent heart is normally fit will be found
useful by all who have school children under their care. He says that
almost any boy w^ho is fit to attend school at all is fit to join in Swedish
exercises. Any healthy child of nine or ten should be able to run or
scamper a hundred yards, yet quite a number cannot. This failure
does not as a rule denote cardiac disease, but it should nevertheless be
noted for further observation. Boys under thirteen should run the
hundred yards in about 14 seconds without serious strain. For boys
under fourteen, time limit is inadvisable for anything above 220 yards.
At the school to which Mumford is medical officer, half-mile sprinting
for boys under sixteen is allowed, with a time limit of 2 minutes 40
seconds ; and the school limit for the mile is 5 minutes 35 seconds.
The time needed for recovery of normal pulse-rate is noted in all
doubtful cases. High and broad jump figures are also given. As for
swimming, he sa,ys the temperature of an ordinary swimming bath
should not be below 70'’-' F., and he points out that the feebler the
physique of the. bathers, the higher must the temperature be.

“ Phrenocardia.” — This is a special type of cardiac neurosis, fully
desciibed by Behrenroth,^ who insists upon its characteristic nature.
He found 19 cases among 370 patients complaining of functional
cardiac disorders, 17 of whom were women, the ages of all the
patients falling between twenty and forty-seven years. The first
symptom is pain, referred as a rule to the left lower praecordium, and
sometimes associated with cutaneous hypersesthesia in the same area ;
the pain is like that of a wound or stab, or else cramp-like. It has
some association with the respiratory movements, and is connected by
various writers with changes in the diaphragm. A result of this
connection is to be seen in the peculiar and characteristic form of
interrupted breathing that accompanies it, in which a respiratory
pause of varying duration is followed by several cogwheel ’’ inspira-
tions. A sighing type of inspiration is often noted. Various altera-
tions of the cardiac rhythm also occur ; on the average, the rate is
quicker than normal , these alterations are accompanied by abnormal
cardiac sensations of varying type, which are classed together under
the head of “ palpitation.’' Physical examination discloses no evidence
of cardiac disease. Spastic constipation is a common accompaniment ;
in some cases the patient shows other evidences of a neuropathic habit,
while occasionally phrenocardia is associated with compensated heart
disease. Attacks may occur which simulate angina, but at the same
time bear some of the characteristic marks of hysteria, one feature
being the excessive bodily restlessness of the patient during the attack.
Chief among the causal factors of this neurosis, Behrenroth places

NEW TREATMENT 279 HEART DISEASES

sexual perversions and dissatisfactions of various kinds. This is ot
importance in regard to treatment, which must have respect to the
cause and the possibilities of correction. Regulation of the patient's
diet and manner of life is of prime importance, and constipation must
be remedied. Among the drugs that are useful, Behrenroth mentions
Bromide^ given for a short time in small doses, Valerian preparations,
and pills of Lupulin with Camphor.

Parkes Weber^ describes a case of mitral dwarfism. Unlike the French
writers, who regard the mitral stenosis and the general failure of growth
as being examples of the association of inborn defects, he thinks the
valvular lesion was acquired and probably rheumatic in his case, and
that, being established early, it interferes with the processes of growth
to such an extent as to lead to dwarfism. As he points out, the
mitral is but one of several forms of cardiac infantilism.

Anders^ gives an illuminating account of hydvothorax complicating
cardiac disease ; of 27 cases, 16 were examples of myocardial disease,
and in 5 of these renal lesions were detected. In 13 of the 16 the
hydrothorax was right-sided only. In spite of the fact that very
large quantities of fluid may collect within the pleural cavities, they
are often overlooked. Careful physical examination, coupled with a
judicious application of exploratory puncture, is the corrective for this
error. Once found, the fluid should be withdrawn by Paracentesis,
and the cardiac condition treated by Rest, Cardiac Tonics, and rather
free Purgation.

Auscitltaiion. — Of all the physical signs of mitral stenosis, Core^
regards the reduplication oj the second sound at the apex as the most
constant and reliable. He bases this opinion on a clinical study of
173 cases.

Schliefs’*^ examination of 273 children without cardiac disease
discovered a systolic bruit in 100 ; about two-thirds of these were
cardio-pulmonary in origin, the remainder being of the “ atonic ” type,
occurring in flabby, anaemic children. The latter is an indication for
treatment of the underhung cause. The gist of this investigation is
to show that it is unwise to accept a bruit alone, without other physical
signs, as proof of the existence of organic disease of the heart in a
child. An equally instructive statement is that made by R. T.
Mackenzie," who examined 266 healthy young men immediately after
brisk exercise, and found a systolic murmur in 74, or 27*8 per cent.
About half of these bruits were purely pulmonic, and their variation
with posture suggests that many belonged to the cardio-respiratorv
class. The large percentage in which these bruits appears should
constitute a powerful warning against a diagnosis of heart disease based
on the development of a bruit duiing exertion.

Arrhythmia {see also Auricular Fibrillation, Auricular Flutter,
Heart Block). — Lead colic is not infrequently associated with
slowing of the pulse. The nature of this bradycardia has been
investigated by Lian and Marcorelles,® whose tracings show that the
whole heart is slowed and that under the influence of atropine the

HEART DISEASES 280 MEDICAL ANNUAL

pulse is quickened, proving that it is due, not to intracardiac disease
but to extracardiac influences acting through the vagus, and probably
toxic in origin. They note that the bradycardia is dependent neither
upon the blood-pressure nor upon the abdominal pain.

Three very remarkable cases of slow irregular pulse are recorded by
Lewis.^ In the first, slowing of the whole heart was confused from
time to time by the appearance of a slower regular rhythm arising in
the auriculo-ventricular junctional tissues. The second case is even
more curious : an otherwise healthy young man had a slow and often
irregular pulse, with entire absence of polygraphic or electrocardio-
graphic evidences of auricular systole — an inexplicable type of
arrhythmia. In the third case, the radial pulse was regular at 26 to
33 per minute, and fits of the Stokes-Adams type occurred ; slowing
was due, not to heart-block, but to interposition of premature beats
arising in the ventricle, every alternate one of which “ retrograded ”
into the auricle.

Windle^° summarizes his experience of the alternating pulse as
exhibited by forty-five patients under his care, suffering from cardio-
sclerosis, post-rheumatic heart disease, pneumonia, paroxysmal tachy-
cardia, and acute rheumatic carditis. In the first type it is not
uncommon ; and whei*ever it occurs it adds to the gravity of the
prognosis, since it presages failure of contractile force.

Technique of methods of investigation cannot be described here. For
accounts of the graphic records of heart sounds, papers by Lewis,
Fahr,^^ Watson-Wemyss and Gunn,i® and Cohen^® may be consulted.
The principles and methods of electrocardiography are discussed by
their master, A, D. Waller.^", The radiological examination of the
heart, an important aid in cardiac diagnosis, is described by Lebon
and Aubourg^^ in a temperate paper. Rautenberg^o gives a brief
account of results collected by his oesophageal method of recording
graphically the movements of the left auricle.

Prognosis. — In a discussion at the Seventeenth International
Congress,®^ Walsh, of Ne-w York, emphasized the importance of
encouraging cardiac patients to think as well of themselves as possible,
the influence of mind on body being particularly well marked in this
class of case. “ The practitioner is justified in giving the best prognosis
he can, or even better still,” to sufferers from morbus cordis : a state-
ment with which all who see many of these patients w-ill cordially
agree.

The outlook in valvular disease is not so universally gloomy as it is
sometimes painted. Heinrich^s quotes examples from his own
experience and from the literature, to show that patients may carry
apparently serious lesions of the aortic and mitral valves for thirty
years or more, and present at the end of that time all the evidences of
adequate compensation. He lays proper stress on the importance in
aortic ’^•alvular disease of considering the cause of the lesion, and its
direct influence on the condition of the myocardium. The syphilitic
and arteriosclerotic cases, in which there is inevitably progressive

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2S1

mterference with the health of the cai*diac muscle, have a poorer out-
look than those in which the valvular lesion follows rheumatism, always
provided the patient has emerged from the decades during which
there is probability of rheumatic re-infection of the heart.

Cautley,-^ writing of the prognosis of heart disease in children, says
much too grave a view has been and is still taken of the slighter
affections ; the outlook depends mainly on the state of the cardiac
muscle. In each case we should find out what is the prospect of
compensation being established and maintained ; the greater the
number of valves affected the less is their prospect, i.e., the prognosis
is worse in combined aortic and mitral disease than in mitral disease
alone. Again, valvular obstruction is harder to compensate for than
mere insufficiency. The state of the myocardium is of particular
importance, since it is always injured more or less in rheumatic carditis,
and often in other infections, such as diphtheria, scarlet fever, and
influenza. Anginal attacks, which he finds not uncommon in children,
are of bad omen. Cautley attaches some importance to what he
regards as a sign of pericardial adhesions, viz., a small rapid pulse in
cases of rheumatic “ big heart in which treatment has been careful
and adequate. The greater or less development of those physical
signs which are directly due to the lesions (e.g., murmuis and thrills)
must also be considered, though these are notoriously disproportionate
to the severity of the lesion; a loud bruit may be functional, or
it may, if organic, prove no moie than that the heart is acting vigorously.
The presence and amount of hypertrophy or dilatation are important
points ; great hypertrophy proves a severe lesion, and a heart near
the limit of its powers, -while persisting dilatation suggests a poor
condition of the myocardium. Dropsy is rare ; when it occurs it is of
grave significance, and malnutrition generally may be regarded as a
measure of the severity of the cardiac lesion. lai rheumatic cases,
much depends on the degree to which the child proves prone to active
outbursts of the infection ; this depends in part on heredity, in part on
social and climatic environment, and is hard to estimate except by
actual observation of the patient’s career.

The prognostic aspects of heart disease in its relation to pregnancy,
were dealt with by various speakers at the German Gynascological
Society’s Congress.-^ Fromme said that of 200 women with heart
disease, 5 per cent died during pregnancy, labour, or the' puerperium,
while between 9 and 17 per cent terminated in abortion or premature
labour. Baisch’s figures relate to 200 pregnant women with valvular
lesions ; in half, symptoms of decompensation were manifest, of a severe
grade in a quarter, while death occurred in five cases. In about half,
the heart was worse after than before pregnancy. Approximately,
one-third of the pregnancies failed to go to term. Kreisler’s statistics
from Dresden, showed that of over 23,000 labours, 26 were induced
artificially on account of cardiac disease ; in 16 of these the lesions
were mitral, in 3 aortic, and in 7 myocardial ; 4 ended fatally, 2
from sepsis.

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Treatment. — Two interesting discussions on the treatment of heart
disease in children emphasise the predominant part played by acute
cardiac rheumatism, and the difficulties that lie in the way of its treat-
ment. Cautley ,25 opening the Royal Society of Medicine discussion,
laid stress upon the need for recognizing that in every case of this
disease the heart muscle is directly injured, a fact which explains
much of the beneficial effect of Rest for such patients. He thinks
Blistering of use if the pericardium is obviously inflamed, and
uses Mercury (as Guy’s pil. digitalis co.) if the liver is engorged.
Mackenzie insisted on the necessity of accurate diagnosis as a prelude
to successful treatment. Hay quoted with approval the statement
of a Viennese professor “ that alcohol should be excluded from the
pharmacopoeia of children.” Carr agreed that digitalis cannot help
a heart which is in the grip of a toxin ; during convalescence, he has
found pure Cod Liver Oil of more advantage than if diluted with malt
and other things. Sutherland added a timely warning as to the harm
which may be done by treatment w’-here none is indicated, viz., in the
” obsolete ” stage of carditis where all active inflammation has died
down. The value of Opium in carditis was spoken to by Morison.

At the British Medical Association meeting, Poynton,^^ after laying
stress on the fact that prevention is better than cure almost more in
regard to acute caidiac rheumatism than in any other disease, because
of the irreparable nature of the damage done, gave his experiences of
Vaccines in this disorder. These were not wide enough to justify
generalizations ; but they show that it is a method to be used cautiously
if at all, as in some cases the injection of vaccine was quickly followed
by serious relapse. The only drug to w^hich he gave special praise was
Theocin Sodium Acetate, given in small doses of 2 to 4 gr. t\vo or three
times a day after food, in tablet form. It is indicated in cardiac
disease accompanied by dropsy. Miller and the present writer declared
their belief in the efficacy of Salicylates wdthin limits ; the drug should
not be overdone, it should be combined with alkalies and purgatives,
and — above all — ^too much should not be expected of it. The damage
that is already done by the infection cannot be repaired by the drug,
the activities of which are practically limited to the prevention of
further injury. Naish, as well as Poynton, said rheumatic children
needed special convalescent homes. The general opinion agreed with
that of most- physicians wdth wide experience of cardiac rheumatism,
that pericardial effusion demanding paracentesis is an almost unknowui
complication of this disease. Another contribution to the same study
is that of Gilbert, 2 7 who lays much emphasis on the need of After-care in
acute rheumatic carditis ; it should be considered as acute over a
much longer period than has been the custom. Treatment should be
carried out over months and perhaps years, until all possible signs of
acute disease have disappeared, and even then, until adolescence is
passed, at least a certain amount of restraint should be exercised. This
statement is borne out by the satisfactory results obtained in his
experience.

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Vaquez’s^^ summary of the Dietetics of heart disease runs counter,
in some ways, to generally received opinions, for he exonerates food
excess from all responsibility for the causation of cardiosclerosis, and
impeaches alcohol instead. He is impiessed with the need for restricting
the general fluid intake, at least in so far as this tends to be excessive.
The use of Sugar in heart disease, introduced several years ago by
Goulston, receives new support from Denyer,-- who gave large quantities
(from half a pound downwards in Hventy-four hours) to an apparently
moribund patient suffering from cardiosclerosis, with surprisingly
successful results.

Capps and Matthews^*^ used the venous blood-pressure — a
subject inadequately studied in Britain — as an index to the value of
the various drugs used in the treatment of circulatory disease. The
work was entirely experimental. Pituitrin and epinephrin raised the
venous as well as the arterial pressure ; alcohol in full doses lowered
the arterial but raised the venous pressure. These effects were probably
induced indirectly through action on the heart. Morphine and the
nitrites lowered venous pressure, apparently by direct action on the
venomotor mechanism.

The therapeutic possibilities of Digitalis are becoming more and
more clearly defined. An important research by Cushny, Marris, and
Silberberg®^ shows that it slows the pulse in some cases by a vago-
inhibitory effect on the rvhole heart, but that in others the retardation
which it produces is unchanged by atropine, and is therefore due, not
to action through the vagus, but is a direct effect on the conducting
fibres which pass from the sino-auricular node to the auricle and from
the auricle to the ventricle. In auricular fibrillation [q.v.) its action is
also direct ; probably it is exerted through an augmentation of the
contractile power of the heart and a consequent improvement in the
myocardial nutrition. These findings apply, not to digitalis only, but
also to its near relatives, strophanthus and squill. Eggleston^^ shows
by clinical observation that the emetic effect of digitalis is due to its
action, after absorption, on the bulbar centres, and not in any way to
gastric irritation. From these data he makes the very important
deduction that, inasmuch as it has been shown that all true digitalis
bodies produce nausea and vomiting by direct central action, it is
fallacious and -wholly irrational to seek to avoid these symptoms
resulting from the oral administration of any given preparation by
resort to another preparation or to another channel of administration.”
He points out that any causation of gastric symptoms which may
follow a change of method is probably due to the fact that the second
preparation or mode of administration is less favourable to rapid
absorption of the drug. [The writer has applied Eggleston’s hypothesis
in the use of digitalis, and finds that it may be given with benefit in the
vomiting of auricular fibrillation. — C. C.]

Bernoulli's has tested the action of digitalis on persons subjected to
graduated muscular exercise, and finds that it has no influence on the
cardiac reaction to strain. From this he argues that digitalis does not

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produce any appreciable tonic effect on health}^ muscle, and that it is
useless to give it for any purpose if the heart be thoroughly compensated.
This is in accord with Mackenzie’s teaching, to the effect that auricular
fibrillation {q.v.) is the great indication for its use. At the International
Congress,®^ Windle said he had found the drug almost as useful in
rheumatic heart disease with regular heart action and dropsy — a rare
combination ; and Cushing and Wenckebach also upheld its value in
non-fibrillating cases. In spite of increasing knowledge as to the
general action of digitalis and similar drugs, we are not yet able to say
w'hat happens under their influence inside the myocardial cells. Clark,®®
working with Strophanthin, comes to the conclusion that it does not
enter into combination with the cell-protoplasm to any appreciable
extent ; that it acts specifically^ on cardiac muscle and not on other
tissues ; and that its depressant action on conductivity- is of a different
nature from its tonic action on systole.

To many, the conclusions of Parkinson and Rowlands®® regarding the
action of Strychnine on the heart will come as a great surprise. They
“ found no evidence that the subcutaneous injection of a full dose of
strychnine in cases of heart failure with a regular rhy^thm, produces
any change in the blood-pressure, rate of pulse, rate of respiration, or
general sy^mptoms within the hour following its administration. In
cases with auricular fibrillation, strychnine produced no change in the
rate or irregularity of the pulse, rate of respiration, or general symptoms
during the same period.” They conclude, therefore, that strychnine
has no effect which justifies its employ^ment as a rapid cardiac stimulant
in cases of heart failure,

Allard®^ and Schubert®® describe their experiences of Cymarin as a
cardiac tonic. This drug is a pure cry^stalline glucoside of Apocymmi
cannabinum. The first writer says it is a powerful and rapidly acting
cardiac tonic, which may well be employed where digitalis has failed ;
and that its intensive diuretic effect makes it doubly useful in the
presence of cardiac dropsy. It may be given by mouth or intra-
venously ; introduced by the latter avenue it acts in a few minutes.
Allard says there is a wide margin between the therapeutic and the toxic
dose, so that it is a drug which involves no risk to the patient.
Schubert agrees on the whole with these statements, but thinks
cymarin weaker than digitalis and therefore to be used first, the
stronger drug being kept in reserve. Its dosage is more accurate
than that of digitalis, and sometimes indeed it produces beneficial
results where the more powerful drug has failed.

An interesting investigation into the effect of Strong Purging in
heart disease, carried out by Neilson and Hyland,®® shows that with
the lowering of the blood-pressure that occurs, the heart is often slowed,
and its action in some \vay enfeebled, so that arrhythmia and other
symptoms may be induced. In all cases where such methods are used,
the blood-pressure must be carefully watched, for those patients who
experience most harm from purgation are also those in whom the
pressure falls most.

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285

The duty of the physician who must induce Diuresis in heart disease
is thus summed up by Hirschf elder (1) Acquisition of knowledge
as to the state of the kidneys by every reasonable means, including
the newer function tests ; (2) Strengthening of the circulation by

Digitalis or its fellows where this is indicated, or, on the other hand,
relief of the cardio-vascular apparatus by a Karell Diet ; and (3)
The use of Theocin or the Saline Diuretics to relieve oedema if the renal
epithelium is not severely injured. Newburgh'^^ has attacked the same
subject from the standpoint of M. Fischer’s belief that accumulation
of acid within the tissues is chiefly’ responsible for the collection of
dropsical fluid in cardiac and other diseases ; he finds, how^ever, that
practice does not confirm this theory, for the administration of alkali
with or without sodium chloride did not induce diuresis in cases of
cardiac oedema, and in some instances proved actually harmful.

Kaufmann and Popper'^^ describe a case of paroxysmal tachycardia
in Avhich they think the new rhythm originated in the region of the
a-v node, and was associated with a varying degree of sino-auricular
block. By giving Physostigmine with Strophanthus the rhythm was
changed to a totally irregular one presenting all the usual evidences of
auricular fibrillation ; this again was converted into a regular pulse
by substitution of Atropine.

The treatment of heart disease during pregnancy came under
discussion at the German Congress referred to above.^* Fromme
said that pregnant women with heart disease but no symptoms, need
no treatment. Medicinal treatment suffices for those whose symptoms
are mild, for primiparae with severer symptoms but no decompensation
preceding pregnancy, and for multiparse who went through previous
pregnancies without disturbance, and w'ho betray no high degree of
myocardial disease. Termination of pregnancy may be indicated at
any month if the above measures fail, or if symptoms of decompensa-
tion return often during the same pregnancy ; particularly if severe
symptoms have been noted in previous pregnancies. As for breaking
of compensation at pa 3 :turition, it may be mitigated by hastening
delivery. Young girls who are subject to severe symptoms of broken
compensation should be strongly dissuaded from marriage. With
these general statements other speakers were in accord.

The British school of cardiology produces book after book of which
it may well be proud. Attention may be drawn here to one just
written by John Cowan, of Glasgow, which is particularly adapted
for the needs of the practitioner. Its two chief merits are these : that
it is written by a man w’ho has examined the subject for himself and
who embodies his own personal experience in this book, and that he has
maintained his sense of proportion by investigating the subject from
every point of view. The result is a handbook in which the new work,
relating chiefly to morbid physiology, is correlated with the older
anatomical and clinical data ; and the dry bones of the latter are
endued with the vitality of the former.

References.-— Med. Jow, 1913, ii, 793 ; ^Dex 4 t. med. Woch. 1913,

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06 ; Jouv. Child, Dis. 1913, 203 ; ^Amer. Jour. Med. Sci. 1913, ii, 15 :

^Med. Chron. 1913, June, 121 ; ^Jahrb.f. Kindevheilk. 1912, Sept. Med,

Jouv. Epit. 1913, i, 58) ; ’‘^Amev. Jour. Med. Sci. 1913, i, '9; ^Presse Mid.
1913, 109 ; ^Qiiart. Jour. Med. 1913, vi, 221 ; ^Mhid. 453 ; ^^Heart, 1913, iv.
241 ; ^^Quart. Jour. Med. 1913, vi, 441 ; Med. Jouv. 1912, ii, 17CO ;

'^‘^Heart, 1913, iv, 147 ; ^°Edin. Med. Jour. 1913, ii, 124 ; ^^Deut. med. Woch,
1913, 1493 ; ^'^Lancet, 1913, i, 1435 and 1513 ; ^^Ihid. ii, 379 ; ^^Presse Mid.
1913. 293 ; ^^Deut. med. Woch. 1913, 1033 ; '^Mancet, 1913, ii, 457 ; ^^Bevl.
klin. Woch. 1913. 723 : ^^Amer. Med. 1913, i. 348; ^^Berl. klin. Woch. 1913,
1138 ; Jour. Child. Dis. 1913, 69 ; “^Brit. Med. Jour. 1913, ii. 785 ;

“"Bost. Med. and Suvg. Jour. 1913. ii, 83 ; -^Presse Mid. 1913, 365 ; ^^Lancet,
1913, i, 1092 ; ^^Jour. Amer. Med. Assoc. 1913, ii. 3S8 ; ^^Heart, 1912, iv, 33 ;
^'^Jour. Amer. Med. Assoc. 1913, ii, 757; ‘■^^Mimch. med. Woch. 1913, 967;
'^Mancet, 1913, ii, 809 ; ‘•^^Brit. Med. Jour. 1913, ii, 89 7 ; ^^Quart. Jour. Med.
1913, vii, 42 ; “'^'^Deut. med. Woch. 1913, 783 ; ’’^^Ihid. 540 ; ^^Jour. Amer.
Med. Assoc. 1913, i. 436 ; ^Mbid. ii, 340 ; -^^Bosl. Med. and Surg. Jour. 1913,
ii, 40; ^^Deut. med. Woch. 1913, 1S22 ; Diseases of the Heart, Edward
Arnold. London, 1913.

HEART, SURGERY OF. {See also Pericarditis.)

Priestley Leech, M.D., F.R.C.S.

Several papers on the treatment of wounds of the heart have appeared
during the year. Stewart,^ of Philadelphia, reports five cases of suture
of the heart; two died and three recovered. He has operated on other
cases ^vhere he felt equally sure a wound of the heart existed, but
exploration revealed no such lesion. In each of these cases of mistaken
diagnosis the thoracic wall was penetrated over the heart, the patient
was profoundly shocked, and there existed a haemopneumothorax ;
in two such cases of gunshot wound the pericardium had been grazed
and contused, but not penetrated. In another case, the bullet lodged
in the pericardium, which contained a few drachms of blood, and the
heart was contused. In two cases of stab wound, the knife had passed
down between the pericardium and the lung. In two other cases of
stab wound of the prsecordium, although the general symptoms of
shock were pronounced, it was found that the knife had not entered
the thoracic cavity.

The heart may be reached by a knife, or a bullet, which has passed
through the skin of the axilla, back, or abdomen. No conclusion as to
the existence of a wound of the heart can be drawn from the amount
of external bleeding. A knife does not leave a straight track, often
the lieart is wounded above the level of the skin wound, as the tissues
glide and distort the track. In four of the cases there were local signs
of haemopneumothorax, and the area of cardiac dullness was replaced
by tympany. In one case, in which the pleura was not injured, the area
of cardiac dullness was greatly enlarged. In all cases but one, the heart
sounds were faint but distinct, and in none could any adventitious
sound referable to the heart be heard. Some of the bizarre bruits
described as indicating a wound of the heart may be due to the passage
of air through the thoracic wall. Subcutaneous emphysema, noted
in four cases, may interfere with satisfactory auscultation. Shock and
profound anaemia were present in all the cases. In two instances the
patient walked for some distance after the accident. Distention of

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HEART SURGERY

the veins of the face, neck, and arms, indicating pressure on the auricles
as the result of haemopericardium was present in only one case. This
sign, combined with an increase in the area of cardiac dullness, is
almost pathognomonic of a wound of the heart: it may follow a w'ound
of the pericardium alone, or a wound of the great vessels within
the pericardium.

He makes a chon dro -cutaneous flap, the size and shape depending on
the situation of the external W'ound. If the pleura has not been
injured, it is of the greatest importance to preserve it intact, and this
can best be done by turning the flap to the left. He was never able to
see the wound in the heart, because there was copious haemorrhage
before it was discovered by the finger. There are cases on record in
which the operator vainly searched for a wound which autopsy after-
wards revealed, A continuous suture was used in all cases, and the
needle was passed deeply, without reference to systole or diastole.
Silk was used in two cases, and in one gave rise to a sinus through which
it was discharged ; catgut was used in the other three. Once a large
branch of the coronary artery w'as tied, and once the descending branch
of the left coronary arterj^' close to its origin, w^here it had been accident-
ally grounded by the needle ; this case recovered. This artery has
been tied four times in the human subject, and only one recovered.
This patient dying five years afterwards, it was found that the w^all of
the left ventricle was the seat of interstitial myocarditis, and in one
place near the apex was greatly thinned. He drained the pericardium
in one case, and a purulent pericarditis followed. The other four were
not drained. He will not drain in future, nor would he drain the
pleural cavity (in three cases an empyema developed where this was
done). He would employ the Auer-Meltzer insufflation apparatus,
clear the blood out of the pleural cavity, and close the thorax com-
pletely ; or if the insufflation apparatus w^as not at hand, close the
thorax completely, and ^withdraw the air by an aspirator.

Mitchell^ reports one, Lucas® two successful cases, one of stab vround
and one of gunshot w^ound ; he recommends massage of the heart for
reviving the heart and drainage of the pericardium. De VerteuiP
reports two interesting cases of stab wound of the heart. One patient,
a boy of 14, was immediately operated on and recovered. In the other
case, five days elapsed after the infliction of the wound before operation
was undertaken ; in this case venous blood filled the pericardium, and
the wound of the heart could not be found. He died, and at the
autopsy a punctured horizontal valvular wound about half an inch
long was found in the right ventricle, half-way betw^een the apex and
base of the heart and penetrating into the ventricular cavity. He
opened the pleural cavity in both cases, and noticed no aggravation of
symptoms. The advantages are freer exposure of the heart and pericar-
dium, thorough examination of the pleural cavity, and removal of clots
if any are present. He thinks an ordinary straight incision gives
ample room, without making a trap-door as suggested by some authors.
He cut away the costal cartilages of the fourth and fifth ribs, and had

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plenty of space. Holladay^ reports three cases, with two recoveries.
Rehn® reviews the surgeiy of the heart and pericardium. As regards
wounds of the heart, he thinks the cases are so urgent that the quickest
way to get to the wound is the best.

References. — ^Ann. Suyg. 1913, ii, 67 ; ^Ibid, i, 296; ^Deut. med. Woch,
1913, 166 ; ^Bnt. Med, Jour, 1913, i, 764; ^N.Y. Med, Jour, 1913, ii, 186 ;
^Bevl. klin, Woch, 19x3, 241.

HEART-BLOCK. Carey Coombs, M,D„ M,R,C,P.

From a number of isolated observations of cases of heart-block, the
follomng points of interest have been collected. That heart-block
of all grades is commonly associated with lesions of the auriculo-
ventricular bundle is now established finnly ; and several cases during
the year go to confirm this (Wardrop Griffith and Kennedy,^ cardio-
sclerosis ; Cohn and Lewis,® syphilis). The coincidence is by no means
invariable, however ; Renon, Giraudel and Thibaut® report a case of
heart-block with epileptiform attacks in which a most careful examina-
tion of the heart after death failed to disclose any lesion of the bundle
or of the nervous system, and similar discrepancies are recorded by
Oppenheimer and Williams,^ and by Rohmer.® At present it is not
possible to explain such cases as these.

The occurrence of heart-block in association with acute infections
is noted by several writers (Rohmer,® diphtheria ; Dykes,® pneumonia ;
Lewus,’ rheumatic infection, pneumonia, B, coli infection). The first
of these writers has shown that it is a very exceptional feature, even
in a disease which attacks the myocardium so vigorously as does
diphtheria ; and the same is probably true of acute rheumatism.®

Symptoms. — Several interesting facts have been reported in regard
to the pulse variations in heart-block. Naish® calls attention to the
possibility of a relatively rapid idioventricular rhythm ; two patients,
whose tracings proved the existence of complete dissociation between
* auricle and ventricle, had pulses often rising to 50 per minute. The
usual rate assumed by the ventricle, when it generates its own rhythm
as it does when^cut off from the normally controlling auricular rhythm
by complete heart-block', lies between 30 and 40 ; so slow a pulse
attracts attention, tracings are taken, and the lesion of conductivity
stands revealed. But when the pulse-rate is not less than 50, it does
not strike the clinician as extraordinarily slow, and in default of
tracings the existence of heart-block remains undiscovered. Naish
also^® describes a case in which there was at times a complete dissocia-
tion between the auricular and ventricular rhythms, so that the
ventricle beat at its own rate ; this idioventricular rhythm was slowed
after periods of extrasystolic arrhythmia such as were apt to occur
after exercise. In Neuhof’s^^ case of complete block, the idioventricular
rhythm became quickened and irregular after the administration of
atropine, and also independently of this ; this alteration being due,
not to extrasystolic arrhythmia, but possibly to partial decrease in the
degree of block by the atropine effect. In a case recorded by the
writer,^® with bouts ©f complete block, idioventricular rhythm passed

NEW TREATMENT 2S9 HEAT EXHAUSTION

Avitilin a few seconds into a normal sequence, ventricular following
auricular systole at *2 -second intervals ; then came a period of normal
sequence, followed by a terminal phase of 4 : i block. The moral of
these and the foregoing pathological observations seems to be that
though the main anatomical and physiological facts of heart-block
liave been correlated with as much precision as in the parallel laboratory
experiments of Erlanger, there is still a fringe of discrepancies and
apparent contradictions which demands further exploration.

By a characteristic aberration in the curve the eleciyocardiograpMc
examination is able to reveal the presence of lesions interrupting one
or other of the two chief branches of the a-v bundle without injury
to the main stem (Lewis, ^ Mathewson^*). At present we know
of no other means by Avhich the presence of such a lesion can be
discovered.

The fits which may accompan^^ heart-block, the combination
of the two phenomena constituting the Stokes-Adams syndrome,
are divided b}^ Wilkinson^^ into three grades — the vertiginous,
the apoplectiform, and the epileptiform. Dumas^^ points out that
slowing of the whole heart may be accompanied by cerebral attacks,
and that these may also coincide with long cardiac pauses such as
may occur in connection AAuth extrasystolic arrhythmia ; the only
connection between heart-block and fits is that of temporary cerebral
anaemia induced by the former and causing the latter, so that other
cardiac irregularities having the same result — cerebral anaemia — are
capable of provoking similar fits. At the same time, however, the
cerebral attacks of extrasystolic arrhythmia and of slowing of the
whole heart are seldom severe, while those caused by heart-block are
often grave enough to threaten life.

Treatment. — Here there is little to be said as yet. Most of the
lesions which have developed far enough to cause heart-block are
alieady out of the reach of therapeutics. Josue and Godlewski,^^
however, claim beneficial results in a case of complete block, following
on the prescription of Graduated Exercise (wallving on the flat and
climbing a staircase). They regard this as due to stimulation of
the auriculo-ventricular connections through the s^^mpathetic nerve.

References. — JSIed. Jour. 1913, i, 1203 ; “Heart, ii, 7 ; ^Presse
Med. 1913, 65 ; ^Jour. Amev. Med. Assoc. 1913 . h 1799 ’> ^Jahrb. f. Kinderheitk.
xxvi, 391 {Presse M ^ d . 1913. 31 S) ; Mancet, 1912, ii, 1008 ; '^B'vit. Med. Jour,
1913, i, 484 ; ^Ibid. 5S4 ; ^ihid. 491 ; '^^Quart. Jour. Med. 1913. Jan. 196 ;
^^Aiiier. Jour., Med. Sci. 1913, i, 513; '^^Bristol Med.-Chir. Jour. 1913, 30;

Med. Pev. 1913, i. 183; ^’^Pev. de Med. 1913, 148; Med.

I 9 i 3 > 374 ; ^^Pdin. Med. Jour. 1913, ii, 233.

HEM EXHAUSTION. Herbert French, M.D., F.R.C.P.

The effects of exposure to intense heat during laborious work, e.g.
in the stokeholds of steamers at sea in hot climates, forms tlie subject
of a long discussion by Fiske.^ The symptoms which result are similar
to, but not identical \rith, those of sunstroke, and their pathology is
soineAA'hat different in that they are in part due to local dehydration of

HEAT EXHAUSTION

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MEDICAL ANNUAL

the muscle tissues, with resultant fibrillary twitching, cramps, and
rigors of great severity. There is pallor or lividity, drenching perspira-
tion, weakness of both voluntary and involuntary muscles, the circula-
tory and respiratory functions being profoundly embarrassed. Sensory
motor phenomena are those of exhaustion rather than of the irritable',
responsive to the least stimulation, type — there is the tendency to
sleep and stupor rather than to convulsions.

Attacks of this kind are familiar to most ships’ doctors who have
been engaged in the tropics ; and Fiske has analyzed the official reports
that have been submitted to the United States Government from time
to time about them. Although alcoholism, the drinking of iced water,
and other etiological factors have received blame on different occasions,
Fiske draws a very definite conclusion that neither the habits of the
men, nor the actual temperature of the atmosphere in which they work,
are nearly so important as the absence of thorough ventilation ; even
when the latter can only be carried out with hot air, the fact of there
being a free draught in the stokeroom minimises enormously the risk
of stokers’ cramp and “ heat ” exhaustion. The paper is one of great
importance, not merely to the medical profession, but still more to
those concerned with navies and the mercantile marine.

Reference. — ^Amer, Jour. Med. Sci. 1913, i, 565.

HERNIA. {See also Intestinal Surgery.)

Sir Berkeley Moynihan, Af.S., F.R.C.S.

Harold Upcott, F.R.C.S.

The occasional occurrence of cysts connected with hernial sacs, and
the duplication of these sacs, is attributed by Murray^ to variations in
the peritoneal attachment of the gubemaculum, and to anomalies in
the obliteration of the processus vaginalis (Fig. 32).

Considering the frequency of hernia in infants, sty angulation is
comparatively rare. According to Collins,® it is most frequent during
the first three months of life, and becomes, less so during later infancy.
Special symptoms in children are violent screaming, recurrent vomiting,
constipation, tendency to retention of urine, and rapid collapse.
Though the sac generally contains small intestine, csccum and appendix
are present more often than in adults. The prognosis is good, provided
operation is performed without delay. The exact method of operation
matters little, provided it is simple and brief.

Friedman® says that in retrograde incarceration of the intestine, two
or sometimes three distinctly separate loops of gut are found in the
hernial sac, while the incarcerated loop is wdthin the abdomen near the
hernial orifice. The organs involved may be the appendix. Fallopian
tube, Meckel’s diverticulum, omentum, or intestine, most often small
intestine. The condition most often occurs in old-standing inguinal
hernia. The connecting loop within the abdomen is apt to suffer from
the effects of the constriction more than the two loops in the hernial
sac, which may be normal or only moderately strangulated. Given a
long-standing, large-sized hernia which has become strangulated,

NEW TREATMENT

291

HERNIA

where there is either fair rigidity or a tumour immediately above
Poupart’s ligament, a diagnosis of hernia en W ” may be made ; and
when at operation there^are present two or three distinct loops of

7, 8 . 9 . 10. II.

att.n-hri'ent m t!u» s!uJxruaiJulurn to tb** peritoneum, and consequent lartiai rliiplication ot tfie processus raginalis.
1 ' s , l'(.tentiil hernu <ae c a . Closed sac. h.-.. Hernia sat, C., Cyst,

12 . 13 . 14 :5

Wnie double artai.bn.frit ,il tl.e ifiiliprtiatuluiu to tiie pcnt.-nvini an 1 . .fisi-ipioiif . .snip!, t,* ,)ii[.lic,it..i' m iJn* iiroiussus

Complete but unequal dupiicatlun of the proeesiius vajrinalis owing to the unequal diMsion of the giiliernueuluiu. The impertect
ebbtcration of these processes results iu the formation ot two sacs (Case 3). o,. Coiitunwl unicnt um t , Contained a Uttle fluid.

32. — Diagrams illustrating the formation of cysts in hernial i-acs. (.Ifurn^v.)

gut in the sac, with fluid escaping from the abdomen, an incarcerated
connecting loop is to be thought of and looked for (F-igs. 33-37)*

Pringle^ has been disappointed in the results of IMayo’s operation
for tmibiHcal hernia, and has also come to modify the method in a

HERNIA

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manner which he considers a distinct improvement A large elliptical
area of skin and subcutaneous fat, including the thin skin covering the
lieriiia, is removed. The vertical breadth of skin and fat which is to
be removed is gauged by holding up the abdominal wall until the large

F/s. 34. — Retrograde incarceration, or hernia
“ en W," as it would appear spread out. («)
Abdominal loop ; (i>) constiiciion rings ; (r) loops
in sac.

3 5- — Heinia '■ en W” with caiciim, appendix,
and portiuii of iieinn in inc. Incarcerated “ connect-
ing loop ” in abdomen.

^ /'>V. 36. — Diagrammatic presentation of
Friedman’s case of hernia " en W.” («) Gan-
grenous loop in abdomen ; (/>) hernia orifice ;
(c) loops in sac, moderate strangulation ;
constriction ring ; Uj mesentery of incarcerated
“connecting loop.”

PLATE XXII.

UMBILICAL HERNIA -conlinued.

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293

HERNIA

suprapubic fold of tissue, present in all these patients, disappears ; the
transverse extent of the wound is anything from 10 to 16 in. (Plate XXL
Fig. A). The removal of this elliptical area is generally begun from
below, and the subcutaneous fat must be removed fairly cleanly from
the underlying sheath. The sac is opened to the ring, all its loculi are
emptied of their contents, which are returned into the abdomen, and
the whole sac is removed. A transverse incision is then made from
each lateral margin of the ring to the outer limit of each rectal sheath
{Fig. J5), and the two portions above and below this incision are
dissected as two flaps off the anterior surface of the recti muscles,
the one upwards, the other down-
wards, the tissues of the stretched
linea also being sj^lit horizontally,
so as to maintain the halves of the
two sheaths in continuity with each
other (Fig. C). This dissection of
the two sheath flaps is to be made
upwards and downwards far enough
to permit easy approximation of the
inner borders of the two recti for the
whole distance in which they are
exposed. One, two, or three mat-
tress sutui'es, according to I'equire-
ments, taking a wide grip, are passed
through the two recti, the posterior
layer of the sheath, and the peri-
toneum. These are drawn tight
enough to approximate the two
muscles, but before they are tied the
now bunched-up posterior sheath
and peritoneum, as well as the
margins of the “ ring ” opening
through these structures, are sutured
in a vertical mesial line ; the mat-
tress sutures are now tied [Ft ate
XXII, Fig. D), and then the two
adjacent margins of the recti are also sutured. A series of sutures is
next placed to carry and fix the cut border of the inferior flap, made
from the anterior sheath of the rectus, as high up behind the upper
flap as possible (Fig. E) ; and then the cut border of the upper flap is
sutured over and in front of the inferior flap (Fig. F) as far down as
it will come, so that good and wide overlapping is obtained. The
margins of the superficial wound are now approximated. If drainage
should be considered necessary, it may be from either angle of the
wound, or through a stab wound, in the tissues of the abdominal
wall just above the pubes.

References. — ^Lancet, 1913. i, 746; -Ann. Suyg> 1913. i. ^Surg.

Gyn. and Obst. 1913, ii, 97; ^Ghisg. Med. Jour. 1913, t 493.

HERPES ZOSTER

294

MEDICAL ANNUAL

HERPES ZOSTER. E, Graham Little, M.D., F.R.C.P,

Pathology. — Montgomery and Culver^ report two interesting cases
of herpes zoster, and contrast the symptoms in detail. In the first
case the eruption was on the lower third of the left leg, and was preceded
by severe neuralgia for about 10 days. The eruption itself was slight,
but the pain persisted after the subsidence of the skin lesions. The
second case affected the area of the first division of the fifth nerve.
This %vas followed a month later by parah'sis of the levator palpebrse,
and six months later by glaucoma of the same eye. The authors
regard herpes zoster as caused by a centripetal infection, derived from
a superficial inoculation of the skin or mucous membrane, and explain
the greater severity of the symptoms in the ophthalmic case quoted
above as compared with the leg eruption by supposing that the virus
has a shorter distance to travel in the first instance, less antitoxin being
generated, and the central ganglionic inflammation being therefore
greater.

Litchfield^ regards “ acute posterior ganglionitis," which is the
anatomical accompaniment of herpes zoster, as analogous to acute
anterior poliomyelitis, and dwells upon the likeness in the prodromal
period of malaise and illness, the limited course, the occasional epidemic
character, evidence of contagion in some cases, and immunity to second
attacks. Leucocytosis has been observed in some cases of herpes in
the post-eruptive stage. The pain accompanying or preceding herpes
zoster may be mistaken for the pain of visceral disease, e.g., pleurisy,
pneumonia, renal colic, appendicitis, etc., and careful search for the
eruption of herpes should be made in all cases of obscure pain.

Treatment. — McNab^ recommends Ionic Medication in the treat-
ment of herpes zoster of the trigeminal, where pain and scarring are
usually maximal. The method used was as follows : An electrode
.attached to the positive pole is prepared of the suitable size, covered
with three layers of lint, and soaked in sulphate of quinine solution ;
a current of i to 1*5 milliamperes for each square inch of surface of
electrode is passed for fifteen to twenty minutes and repeated in seven
to ten days. The neuralgia which often persists after herpes may be
usefully treated by this means, even though the patient may not come
for treatment, as happened in a case detailed by the author, for many
weeks after the onset of the disease.

References. — '^Jour. Amer. Med, Assoc. 1913, i, 1692; ^Ibid. 1691;
^Lancet, 1913, i, 821.

HIP JOINT, OSTEO-ARTHRITIS OF. Priestley Leech, M.D., F.R.C.S.

Sampson Handley and BalP describe an operation, which they call
Cheilotomy, for restoring the movement and function in certain cases
of osteo-arthritis of the hip. They report two successful examples.
In both, the condition followed an old injury to the hip. The operation
consists of opening the hip joint and removing the lipping on the edge
of the femur. The restoration of movement, while probably depending
mainly upon the removal of actual bony obstacles to rotation and

NEW TREATMENT

295

HYPERTRICHOSIS

abduction, may also be partly due to restoration of ''slack” in the
capsule of the joint. The head of the femur is unduly large, and this
tightens the capsule ; with the removal of some of the bone, the head
is lessened, and thus there is more room in the capsule. They consider
the method unsuitable where the constitutional or toxic element of
osteo-arthritis predominates ; these cases they think are best treated
by vaccines.

Wheeler, of Dublin, ^ records a similar case operated on three months
before Handley's. He first removed ” lipping ” from the tibia of the
left knee-joint, and, as the result was so good, removed some bone from
the head of the femur, vdth an equally satisfactory result. Every form
of treatment, including the use of vaccines and serums, had been tried
in vain ; and Wheeler thinks that the operation need not be confined
to so-called ” traumatic ” cases ; the etiology matters little if the
pathological changes are the same.

Albee^ reports 31 cases in which he produced ankylosis of the hip ;
20 were arthritis deformans ; 9 tuberculosis ; i an ununited fracture of
the neck of the femur ; and i a “ cured ” tuberculous hip.

MacKenzie Forbes,-* of Montreal, in cases of one-sided hip disease
of this kind, recommends excision of the anatomical head of the femur,
and replacement of the neck into the acetabulum. The limb is kept in
extreme abduction for a period of at least six weeks, in an endeavour
to form a new fibrous head over the incised neck. The osteophytes
round the rim of the acetabulum are also chipped away.

References. — Med. Jour. 1913, i, 929 ; Mbid, 9S9 ; ^Post Graduate

1912, xxvii, 1017 {Surg. Gyn. and Ohsts. 19 i 169); *N.Y. Med. Jour.

1913, ii, 614.

HYDROPHOBIA. [See Rabies.)

HYPERTRICHOSIS. E. Graham Little, M.D., F.R.C.P.

Treatment. — For permanent removal of hair the sole satisfactory
method is by Electrolysis. For temporary removal Freshwater*
considers the methods of plucking, sha\-ing, cutting, and singeing,
all of which in suitable cases may be recommended. Depilatories
have no permanent effect. There are several formulae, e.g. : —

R Piilv. Orpiment. 5*3 1 Calc. Hydrat. §j

or concentrated solution of Barium Sulphide made into a paste with
starch ; or : —

R Barii Sulphidi 5 **j f Amyli aa gj

Pulv. Zinci Oxidi I

The sulphide should be fresh ; otherwise its action is unsatisfactory.
At the time of application, sufficient water should be added to make
a paste, which is then spread over the hairy part and permitted to
remain two or three minutes, or until a sensation of heat or burning is
felt. It is then quickly removed by scraping with a wooden spatula,
and the skin is thoroughly washed with warm water ; after dr3dng, the
skin should be covered wnth cold cream. ^

HYPERTRICHOSIS

296

MEDICAL ANNEAL

In prescribing a depilatory, the patient should be informed that
its action is only tempoiary, and that it must be repeated after a
variable period. Further, when first applied, it should only be
allowed to remain on the skin a short time, in order to ascertain
the tolerance of the skin to its. action, even if the removal of hair is
incomplete.

When the hair is very fine, but annoyingly visible, Bleaching by
Hydrogen Peroxide (10 volumes) effects much improvement and is
safe. For bleaching the hair on the arms and legs, Sodium Peroxide
Soap (2-i- to 20 per cent) left on the skin for five to tv'enty-five minutes,
is useful. Rubbing the hairy area with Pumice Stone is also a useful
home method. To commence with, the hair on the chin or lip should
be cut short or shaved. A piece of pumice-stone without rough edges
is selected, the artificial pumice-block being the best for the purpose,
and rubbed gently o\'er the part to be treated against the direc-
tion of the hair growth, for a few minutes twice a day ; the friction
should not be so severe as to damage the skin, and afterwards, a little
cold cream should be rubbed in. This should be carried out for six
months, during which time the part will be free from hair. A rest of a
month is then enjoined, in order to see the effect produced on the
hair growth ; in a large number of cases, it will be noticed that the
hair growth is weaker, that is, where, previously, thick pigmented
hairs grew, now finer hairs appear. Another six months' rubbing is
ordered, and at the end of this period in some cases the hair is practically
destro5'ed, while the rest shows a marked diminution in number and
size of the hairs. After this, an occasional rubbing will be sufficient
to keep the growth invisible. Freshwater expressly cautions against
the use of .r-rays for any exposed area such as the face, owing
to ^the risk of permanent telangiectasis and other disfigurements.
A method of punching out hairs wdth a special machine devised by
Ki'omayer is also described, but it has been little used and is not
very practical.

Electrolysis is the method of election, and is thus performed. The
patient is placed in a semi-recumbent position and in a good light. The
region to be treated should be sponged over with ether to free it from
grease. A fine steel needle (No. 12), or platinum or gold needle, fitted
to a holder, is sterilized, attached to the negative pole of a batterj^
and plunged into the follicle ; the patient then makes the circuit by
grasping the positive electrode. The current should read about i-J
milliamperes, and from thirty to forty seconds are required, the end of
the reaction desired being marked by frothing in the follicle, when
the patient drops the electrode and the needle is withdrawn, and the
hair removed by gentle traction with forceps. After each sitting the
patient bathes the part with hot water and anoints with cold cream.
The scab formed falls off within a few da^^s.

Reference. — "^Pract. 1913, i, 825.

HYPNOTISM. {See Suggestion.)

NEW TREATMENT

297

INFANT FEEDING

INFANT FEEDING. Frederick Langmead, M.D., F.R.C,P,

All workers among infants, whether medical or lay, are almost
daily brought face to face with avoidable suffering and death, due to
unnecessary weaning. Much of tliis is due to ignorance, neglect,
and poverty, but much also must be attributed to the irresponsible and
light-hearted way in which weaning is advocated by many medical
attendants. As Dr. Lucy Naish^ points out, few medical men
appreciate the difficulties attendant on the commencement of lactation,
and the mother, lacking intelligent and sympathetic help, often lapses
into a course of feeding which would otherwise be avoidable. Few
mothers understand that the crying of their babies in the first two days
of life is not the cry of hunger. The consequence is that, already
exhausted by child-birth, they are worked into a state of anxiety
which pre^■ents sleep and affects the mammary functions, Man}^
babies have difficulty in suckling at first, and may show an aversion
for one breast, quite apart from any abnormality in the gland. If the
position assumed during these early attempts is not comfortable for
the mother, she may feel cramped and tired before any proper suckling
has taken place. Dr. Naish recommends that the baby be laid across
the mother’s body and a pillow placed under the arm which supports
the child’s head.

For cracked nipples, she advises avoidance of the commonly-used
hardening agents, strict limitation of the time of suckling during the
first few days, and the application of bland ointments and fomentations.
After-pains induced by suckling are often very intense, and an assurance
that this is really beneficial is a great comfort to the mother, and
removes one more hindrance to lactation.

When the “ draught ” appears, there is a sharp cutting pain radiating
through both breasts. If the infant elicits the “ draught ” by mouthing
the nipple without firmly catching hold, the breast soon gets soft again,
and this is often mistaken by the mother and the nurse for an indication
of a poor supply of milk, A mother should be informed beforehand
that the breast only secretes while the sucking action is going on, and
that if this stimulus is not present, the gland will become softer. The
secretion of the breast tends to be periodic, and if the baby is not fed
when the flow is active, the milk runs away. This shows that it is
best to feed the baby at the optimum time of secretory activit}^ and is
evidence of the value of regularity in breast-feedings. During suckling
the breast-milk floAVS much more rapidly during the first few minutes,
and as shown by test feeds, the baby will receive during the first three
minutes about two-thirds of its average meal. This vigorous floAv
may irritate the back of the child’s throat and cause it to choke, so that
it screams and refuses to suck. This may be ascribed by the mother
to unsuitability of the milk, and she should be warned of the possibility
of its occurrence.

The crying of the baby is often taken as meaning an insufficient
supply of milk. The best Avay of investigating this is by the test feed,
weighing the baby before and after on sensitive scales A fairly

fNFANT FEEDING

298

MEDICAL ANNUAL

adequate estimate, however, may be made by using a pump on the
opposite breast while the baby is sucking. Abstraction of the milk
b}^ a pump, when the baby is not stimulating the breast, gives an
erroneous idea of the amount of milk secreted, and the mother needs
very little persuasion that her milk is inadequate for the baby.

Rest and freedom from excitement, which are essential to a suckling
mother, are often difficult to obtain because of headache and sleepless-
ness. Dr. Naish recommends Phenacetin and Caffeine for the trouble-
some headache, and Bromides at night to enable the mother to sleep.
A large number of weanings take place because the mother is not
sufficiently shielded from worries during the first few weeks, a truth
■which furnishes a particular reason for keeping her in bed during this
time. Babies are taken off the breast because the mother '' cannot
stand the strain,'' but something else should be given up rather than
the natural food of the child. This author believes that there are
certain times when the milk tends to fail and when w^eaning is particu-
larly apt to occur. These dangerous times are the ninth day, the third
week, the sLxth week, and the beginnings of the third and fourth
months.

Cran^ writes of the abuse of the weighing-machine in the maternities
of France, which he ascribes with Variot to a too rigid adhesion to the
rule laid down by Budin, that no more than 100 grams of milk per kilo
of the weight of the infant should be given in twenty-four hours if
disorders from overfeeding are to be avoided. Variot considers this
quantity too small, and favours a daily amount of one-sixth of the body-
weight during the first three months. The fear of overfeeding has led to
many instances of underfeeding, the symptoms of which are not gener-
ally recognized. The child shows signs of hunger, and is shrivelled and
wasted. Vomiting and diarrhoea occur, contrary to what might have
been expected, and these gastro-intestinal symptoms disappear when
the proper quantity of food is given. Fear of overfeeding has also
led to suckling at one breast at a meal, which may be very right in the
first few weeks, if the milk flow is abundant, but if persisted in in all
cases beyond the first two months of life, will often prove fatal. Cran's
contention is that the baby's stomach cannot be treated as though it is
a test-tube, that the child on the breast can suck until its appetite is
appeased, and that, if the child and mother are healthy, frequent
weighings do more harm than good. Once or twice a week is enough.

Forsyth^ has made a continuous estimate of the consumption of
breast-milk by an infant of the better class from the fifth day after
birth until the forty-ninth day. Considerable daily variations were
observed, a difference of as much as 60 per cent occurring in the fourth
week, but despite these, gain in weight was continuous. The amount
of individual feeds was found to be equally variable, and the same
breast, after approximately equal periods of rest, yielded very unequal
quantities of milk. These observations show the uselessness of a'ttempt-
ing to estimate the amount of milk yielded daily by multiplying the
amount taken at one test-feed by the number of daily feeds.

PLATE XXI 11

BREN NEMANN’S EXPERIMENTS ON CURD FORMATION

Pig, A. — A, Curds of one quart of raztf whole milk returned from the stomach after two
hours ; B, Curds of one quart of boiled whole milk returned from the stomach after two
hours.

Fig-. B.—A, Curds of one quart of razu whole milk returned from the stomach after li\e
hours; B, Curds of one quart of boiled whole milk returned from the stomach after three
hours.

From Dr. T. B re n item and s Paper.

Illustrations kindly lent by American Medical Association.

MEDICAL ANNUAL, jqi.{

NEW Treatment

299

INFANT FEEDING

Eustace Smith^ formulates thxee simple rules for the artificial feeding
of infants, (i) “ Take care that the infant is bathed as quickly as pos-
sible in hot water, and that its feet and legs are never allowed to get
cold.'’ (2) “ See that a sufficent variety of flavour is contained in the
several meals.” (Two differently tasting foods may be given alternately
in the day and a third at night ; in exceptional cases, a greater variety
is required). (3) “ See that the feeding apparatus is absolutely clean,
the food fresh, and the sanitary arrangements generally in good order.”
Milk should be kept outside the living-room ; cream is only to be used
if quite fresh ; foods are not to be allowed to stand for hours after
being mixed ; and highly perishable articles, such as whey and barley-
water, must be made fresh as required. Whey is not to be depended
upon after four hours, nor barley-water after six. The practitioner
should personally look into the conditions under which the child is being
brought up, and do his best to remedy, without dela)'-, any carelessness
or neglect in the nursery. By this means he will be far more likely to
bring about the result he desires than by any ingenuity he may show
in devising a food, or care in’ prescribing the exact proportions of
casein, sugar, and cream to be allotted to the several meals.

The relative value of boiled and unboiled milk is still a bone of conten-
tion. Morse ^ details the changes produced in milk by heat and the
conflicting views held as to the relative advantages of raw, pasteurized,
and sterilized milks. The disturbances which the cooking of milk
may cause are slight and insignificant in comparison with the diseases
caused by infected milk. He advises that all milk, except the cleanest,
should be cooked before being used as a food for infants. Lane-Claypon,
as the result of a careful study of the available data bearing on the
question, sums up by saying that such small differences as have been
found in the nutritive value of raw and boiled milk, have been in
favour of boiled milk.” Brennemann® has performed a series of
experiments which show that both in vitro and in vivo, when rennin is
added to raw milk, the milk will quickly fonn a dense, hard coagulum,
which rapidly and completely separates from the whey. Boiled milk
under the same conditions coagulates more slowly, separates less
completely, and forms a soft, finely divisible curd which differs but
little from a thick liquid {see Plate XXIII). Although not advocating
the exclusive use of either, he considers that the casein of raw milk,
unless modified so that it wall not form hard, large coagula, offers
serious difficulties in digestion that are not present in boiled milk.

Morse favours Pasteurization, holding that whilst it is somewhat prob-
lematical how much influence the changes in milk induced by heat have
on the development and well-being of the infant, it is wise to avoid
them as far as is consistent with the destruction of pathogenic micro-
organisms. He recommends heating the milk at 60® C. for twenty
minutes, for at this temperature there is no change in the taste, odour,
or colour of the milk, and no noteworthy alteration in its chemical com-
position. The ferments and bactericidal action are unaffected, whilst
bacterial toxins and non-spore-bearing micro-organisms are destroyed.

INFANT FEEDING

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MEDICAL ANNUAL

Pfender’ believes clean and raw cow’s milk, modified to the require-
ments of the infant, to be the best artificial food, but has found pasteur-
ization at 68° C. for twenty or thirty minutes more satisfactory in actual
practice. He, however, records a case of infantile scurvy in an infant
fed in this way.

The writer^ has contributed a paper concerning his further
experience in the use of Whole Citrated Milk, first suggested by Sir
Almroth Wright, The sodium citrate is prescribed most satisfactorily
in the form of a solution, and added to the milk in the proportion of
2 grains to the ounce. Either before or after its addition, the milk is
brought to the boil, for this enhances the effect of the citrate and
renders the non -spore-bearing micro-organisms innocuous. Healthy
babies may be fed on citrated whole milk from as early as a fortnight
after birth, and do not require feeding more often than every three hours
by day and once nightly. The surest guides to the amounts required
are the baby’s appetite, the weight chart, the state of the motions, and
the general progress. The advantages of whole citrated milk are the
small volume of the feed, the simplicity of its preparation, the little
manipulation required, and the absence of the need for adding cream,
a substance which is expensive, variable in its constitution, often rich
in micro-organisms, and in the summer months doctored with preserva-
tives. After watching some hundreds of babies fed in this way, the'
writer is convinced of its value, the failures being surprisingly few.
Rickets, gastric dilatation, general hypotonia, and the puffy and pasty
appearance so commonly seen in babies fed on diluted milk, do not
de\'elop. The muscles are particularly strong and firm. Another occa-
sion for citrated milk is at the time of weaning. Eighty consecutive
marasmic infants were fed in this way, and their progress noted by
frequent weighings. All gained in weight, a result which was very
satisfactory, since previously all were wasting, and on very many kinds
of food. One died of epidemic diarrhoea and vomiting, and five
developed diarrhoea and vomiting in the summer months from which
they I'ecovered, but apart from this no serious gastro-intcstinal disturb-
ance occurred.

The school of Finkelstein and Meyer continues to attract many
adherents. According to Morse,® these authors believe that the
diari'hoeal diseases of infancy originate in a functional weakness of the
intestine, that this weakness is kept up and increased by fermentation,
of which sugar is the special and primary cause. The fat is never at
fault primarily ; it is injurious in that it causes an acid fermentation.
The fermentation of sugar is dependent on the concentration of the
whey, and the relative proportions of casein and sugar in the mixture.
They conclude, therefore, that the principles governing the preparation
of a food to combat intestinal fermentation are : a diminution in the
quantity of milk sugar and of salts by dilution of the whey ; and an
increase in the casein, with varying and, under certain circumstances,
not inconsiderable, amounts of fat. They consequently developed
a food to meet these indications which is known as “ Eiweissmilch ”

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INFANT FEEDING

(method of preparation described in the ^Medical Annual, 1912).
It is prepared with precipitated casein and buttermilk, and is afterwards
boiled. Its composition is : Fat, 2*5 per cent, lactose 1*5 per cent,
proteid 3 per cent, salts 0*5 per cent. They claim that with this
mixture the loose green stools are quickly changed. It is, however,
insuhiciently nutritious, and they advocate, therefore, the addition
of malt-sugar or dextrin-maltose preparations after the acute s\nnptoms
are over, holding that maltose, on account of the rapidity of its absorp-
tion, does not cause a recurrence of the excessive fermentation.

Morse points out that by using mixtures of precipitated casein
(prepared by Finkelstein and Meyer's method), water, and cream, it is
possible to obtain any desired percentage of fat and casein, with very
low percentages of lactose and salts. He has used this method in
many cases, and is convinced that there is a variety of intestinal
indigestion in infancy which is relieved by reducing the sugar and
salts, and by giving large amounts of casein, and that the dextrin-
maltose preparations can be given to those patients sooner than lactose
without causing a return of the s^nnptoms. This type of intestinal
indigestion may be either acute or chronic, and is characterized by
frequent loose stools, green in colour, often frothy, acid in reaction,
and not infrequently containing mucus and fat curds. Unfortunately,
precisely similar stools may be due to bacterial infection, in which this
form of treatment may do material harm. He prefers lactose to
maltose for feeding normal infants. He considers that maltose is
contraindicated in the treatment of diarrhoea due to the gas bacillus
and similar organisms, and is less useful than lactose in that caused
by the dysentery bacillus,

Neff^® has employed with success milk prepared by Finkelstein’s
method, but in which the whey elements have been increased beyond
those of “ Eiweiss ” milk. Tins has been attained by using butter-
milk only as the diluent for the curds, instead of half buttermilk and
half water.

Chapin^^ belie\'es that the best method of preparing an artificial
food for infants is to use as a basis, milk or top milk diluted with Cereal
Gruels of definite strength for their mechanical effect on the curd of the
milk, and then, by altering the character of the carbohydrates, adapt
them to the energy and digestive requirements of the individual infant.
The method consists in using gruels made from various cereals as a
starting-point, and then by means of diastase converting the starch
into soluble starch, dextrin, or maltose as may be required. The
extent of conversion of the starch is regulated by the digestive power
and needs of the infant. A nearly complete conversion into maltose
is indicated when rapid assimilation is required. To obtain the
maximum amount of maltose, the conversion should take place at about
150° ^F., but when soluble starch and dextrins are indicated the
temperature should be at about 165° F.

Proprietary Foods are only advisable under certain special conditions,
and shoifid not be used as a routine in feeding normal infants. How-

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ever, as H. C. Cameron^- shows, by an intelligent use of them much
can be accomplished. He divides them into seven classes : (i) Condensed
milk with a high percentage of added cane sugar, {2) condensed milk
without added sugar, (3) dried milks, (4) dried milks with added malted
sugar, (5) pure malted sugar, (6) foods consisting almost entirely of
unaltered starch, (7) foods consisting of mixtures of unaltered starch
and malted sugar. According to this author, the infant with green
watery stools, vomiting, colic, ulceration of the buttocks, and a slightly
raised irregular temperature, benefits almost always by a change to a
whole-milk diet. Such infants are commonly fed on proprietary foods
containing an excess of sugar or starch, or upon a milk mixture to
which large amounts of cane sugar have been added. Infants who
cannot digest the fat of cow’s milk, suffer from profuse vomiting, often
of curdled milk, and are either constipated or pass bulky, white, greasy,
and foul-smelling stools. A change to a fat-poor, sugar-rich diet
usually causes the symptoms to cease at once. Certain babies fed on
cow’s milk, although they are free from diarrhoea and vomiting, remain
small and ill-developed. They are pale, flabby, and constipated. The
stools are large, bulky, and pale, or hard and pellet-like, and are always
alkaline to litmus. In such cases, the addition of carbohydrate
produces immediate improvement. In young infants showing this
condition, the use of a malted sugar or of dried milk with added malt
is indicated. At six months, one or more feeds made with the addition
of some starch-containing food may be advisable. After six months
it is often found that infants who react to increase in the amount of
sugar by developing diarrhoea will tolerate starchy forms of carbo-
hydrate well. Extract of Malt agrees well with the milk-fed baby,
but aggravates the disturbances of sugar-fed children, whilst Cod-
liver Oil has properties just the reverse.

References. — '^Lancet, 1913, i, 1657 ; ^Ihid. 1659 ; 1656; ^Brit,

Med. Jour. 1913, i, 1263 ; ^Jour. Amer. Med. Assoc. 1913, i, S75 ; ^Ibid.
575; "^Med. Bee. 1913, i, 704; K 4 mer. Med. 1913, i, 36S ; ^Amer. Jour.
Med. Sci. 1912, ii, 640 ; ^^Jour. Amer. Med. Assoc. 1912, ii, 2213 ;

2221 ; ^^Brit. Med. Jour. 1913, i, 872.

INTERMITTENT LIMP. {See Arteriosclerosis.)

INTESTINAL SURGERY. {See also Abdomen, Gunshot Wounds of ;

Diverticulitis ; Hernia ; Visceroptosis.)

Sir Berkeley Moymihan, M.S., F.R.C.S.

Harold Upcott, F.R.C.S.

An encouraging case is recorded by Dowd,^ who successfully resected
about a third of the colon for irreducible intussusception thirty-seven
hours after the onset of symptoms, in an infant flve days old. The
cut ends of the colon \vere invaginated and united b};^ side-to-side
anastomosis. At the time of the report the wound was healing satis-
factorily. He was able to collect only six cases of recovery after
resection in infants less than one year old.

In an interesting paper on the surgical aspects of Meckel's diuerii-
cuhim, Drummond- records 22 cases of acute abdominal disease caused

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INTESTINAL SURGERY

by diverticula, occurring in twelve years in, the Royal \'ictoria
Infirmar\’, Newcastle. These illustrate the majority of the dangers to
which this remnant may give rise XXI T^). In 7 cases, an inverted
diverticulum had produced intussusception of the small intestine ; in
14 cases, acute intestinal obstruction resulted, in 5 of which it acted as
a band over which a coil of intestine was looped ; in i case, gangrene of
the diverticulum only was recorded. Drummond thinks that as a rule,
a certain type of di\*erticuluni is responsible for a certain type of lesion :
an unusually long one will cause intestinal obstruction, and may become
inflamed or strangulated from interference with its blood-supply ;
one adherent to the umbilicus may cause strangulation or produce
a secondary volvulus ; while small, cone-shaped diverticula are liable
to become inverted into the bowel and cause intussusception.

It is difficult to distinguish the symptoms of acute diverticulitis
from those of appendicitis, though intestinal obstruction is more
common in the former, where it is, indeed, frequently the primary lesion.
A typical case of diverticiiUtis of the sigmoid is recorded by Eisenberg,^
who has collected 50 cases of a like nature from the literature. His
patient was a man of 45, suffering from constipation, with the passage
of blood and mucus in the stools. Recently he had had pain in the
left iliac fossa, and vomiting and rigors. There had also been a rapid
loss of weight. In the left iliac fossa a fiat tumour could be felt. It
was rather fixed, and seemed adherent to the abdominal wall. The
sigmoidoscope showed nothing abnormal. Operation was undertaken
upon a diagnosis of carcinoma of the colon. On opening the abdomen,
a tumour of the sigmoid was found, adherent to the parietes and the
bladder ; this was resected and the ends of the bowel were anasto-
mosed. Recovery followed. Examination of the specimen showed that
the tumour was due to inflammatory reaction around diverticula.

The late results of short-circuiting the large intestine are studied in an
interesting paper hy von Beck,-^ whose results may be summarized as
follows : 10 cases of cancer of the large bowel died from four to

twHve months later ; of 10 cases of extensive ileo-caecal tuberculosis,
3 died of phthisis three to six and eight years later, while 7 are well
from four to ten years later ; 32 cases -were operated on for colitis or
pericolitis, 6 of whom had a recurrence of pain after the operation, a
fsecal accumulation being found in 2 of these at a second operation in
the excluded loop of large bowel. He concludes that entero-anasto-
mosis is well suited to the treatment of ileo-csecal tuberculosis. The
results of short-circuiting the large bowel in nervous women are not
satisfactory.

According to McGavin,° transverse colostomy possesses distinct
advantages over the usual iliac route as the operation of election,
viz. ;

(i) Good sphincter control. The transverse colostomy eliminates
the factor of gravit5^ %vhich in the iliac operation is constantly tending
to force the faeces through the opening. It also allows an effective
artificial substitute for the natural sphincter.

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MEDICAL ANNUAL

(2) Firm support for belt and plug. A belt in this position is secure
and does not tend to ride upwards. A greater pressure of the belt
can be supported here, where the recti are at their strongest and are
backed by a strong aponeurotic sheath.

(3) Freedom from prolapse.

(4) Accessibilit3^ With an opening in the transverse colon it is
easy for the patient to lean forward over a receptacle while sitting
down, and the position is conveniently placed for cleansing.

(5) Good spur-formation is possible owing to the length of the
mesocolon.

(6) In cases of temporary colostomy the reconstitution of the bowel
is effected far more easily when the opening is made in the transverse
colon.

In this connection it is of interest to read Keen's® description of the
details of a satisfactoiy’’ dressing devised by a patient 'who has had an
inguinal colostomy for twenty years. The bowel ends normally protrude
about half an inch outside the abdomen. By suitable attention to
diet the bowels should be regulated to act every morning ; the motions
are never under control as with a normal sphincter, but they always
give fair warning.

The details of the protective dressing are most important, for this
must take the place of the normal sphincteric control. The patient
lying on his back with a many-tailed bandage spread out beneath him,
a piece of cotton-wool is first wrapped round the bowel ends. A layer
of wool, 8 in. by ii in., is then laid over the abdomen, reinforced at
the bottom by another piece 3 in. wnde. This is to afford better
support for the flange of the truss and to increase absorption. Over
this pad is laid a smaller piece of linen, then another sheet of wool —
sjAit thin — and finally another square of linen covered with a piece
of rubber cloth 5 by 6 in. square. These pads are arranged so as
to extend more fully to the side and below the colostomy opening than
in the opposite directions. The many-tailed bandage is then fastened
up, beginning with the lowest lap, and secured with safety pins ; its
perineal ends are then drawn up and pinned. The pads should project
about half an inch below the lowest lap of the bandage. Next, standing
up, the patient adjusts his truss. This constricts the lower edge of the
bandage, holding it tightl}’ to the groin- and making the bandage and
pads a safe reservoir even with liquid discharges, if they are not too
profuse.

Back' records a rare case of incarceralion of part of the colon in ihe^
lesser sac, occurring in a man aged 41, who was suddenly seized with
very acute pain in the right half of the abdomen, mainly abo\’'e the
umbilicus, and vomiting. The pain was paroxysmal in nature, each
attack being worse than the preceding one. He had not passed flatus or
faeces for thirty-six hours. When seen, he was in great agony, sweating,
and crying for relief. The whole of the right side of the abdomen was
retracted and rigid ; the upper part of tlie left abdomen was also rigid,
but less so. No swelling could be felt in the abdomen. The man was

XEW TREATMENT 305 INTESTINAL ULCERATION

thought to be suhering from acute appendicitis with perforation, and
operation was at once proceeded with. Incision over the right iliac
fossa revealed no evidence of peritonitis ; the caecum and ascending
colon could not be found. Through a median incision above the
umbilicus, a tense swelling w’as discovered just to the right of the mid-
line, beneath the edge of the liver, and between it and the stomach
Tliis was at first thought to be an inflamed gall-bladder, but eventually
it proved to be a portion of the ascending colon which had made its
way into the foramen of Winslow, followed by the whole of the caecum,
and had then ruptured the gastro-hepatic omentum, so that it lay under
the parietal peritoneum. It was tightly incarcerated, and in a few
more hours mu&i: have been strangulated. After it had been emptied
of gas. Back was able to reduce the hernia and restore the caecum to
its normal position. The patient made a good recovery.

References. — ^Ann. Suvg. 1913, i, 713; '^Snyg. Gyit, and Ohst. 1913,
i, 656; ^Beitv. z, klin. Chir. 1913. <^27; 330; Med. Jour. 1913,

L 9S0 ; ^Joiiv. Amer. Med. Assoc. 1913, i, 1419 ; ’^Lancet, 1913, ii, 17.

INTESTINAL ULCERATION IN CHILDHOOD.

Frederick Langpnead, M.D., F.R.C.P,

Simple ulcer of the duodenum is usually regarded as one of the rarest
of diseases in children. Moynihan, however, was able to collect
sixteen cases from the literature. Such ulcers have been known to be
occasionally present in melaena neonatorum, and have been thought by
some to be the source of the bleeding, but by the majority to be a
secondary result of haemorrhage into or beneath the mucous membrane.
Walther Schmidt^ states that duodenal ulceration in the first year of
life is commoner than is generally believed, and indeed is most frequent
at this period. He bases his opinion on the results of 3824 consecutive
autopsies. He found that i*8 per cent of children who died in the first
year of life showed this condition.

Sidney Phillips^ has described a fatal case of widespread ulceration
limited to the small intestine, in a boy, aged 10. The patient had
severe abdominal pain, with periods of quiescence, for some four
months. The abdomen was tumid and tender. At the beginning of
the illness some vomiting occurred, but this soon ceased. There was
no diarrhoea, nor was blood or mucus passed by the bowel. The
temperature did not rise above 99*2'^ F. At the post-mortem it was
seen that the small intestine for about its middle third was of a deep
red colour, and there was a good deal of haemorrhage into the mesentery.
There was no thrombosis of the mesenteric vessels. Within the intes-
tine it was seen that large irregular areas were entirely denuded of
mucous membrane, the submucous and muscular coats being exposed.

A few defined shallow ulcers were found. The large bowel was quite
healthy. The condition exactly resembled that found in the large
intestine in cases of acute ulcerative colitis. The explanation of the
case was obscure, and he had been unable to find a similar one in the
literature. The writer,® in the discussion which followed, recorded a

INTESTINAL ULCERATION

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MEDICAL ANNUAL

case \’ery like the above. It was that of a boy, aged 9, who died
from uraemia, which was associated \\dth abdominal distention and
tenderness, and diarrhoea. The last part of the small intestine was
very engorged and almost denuded of mucous membrane. The case
differed in that an intoxication — that of uraemia — ^w’as the direct cause
of death.

References. — ^Bevl. klin, Woch. 1913, i, 593 ; ^Brit. Jour. Child. Dis.
1913, 154; ^Proc. Roy. Soc. Med, vi, 1912, 13.

IRIS, CILIARY BODY, AND CHOROID, DISEASES OF. (See also
Medical Annual, 1912, 208.) A, Hugh Thompson, M,D,

Etiology. — These three structures, forming as they do the vascular
coat of the eyeball, are collective!}^ known as the uveal tract. Inflam-
mations affecting either one of them are apt to spread to the other two,
and have therefore in recent years been classed together and termed
uveitis. Three well-recognized causes of uveitis have long been known,
the first of them common, the other two rare : syphilis, tubercle, and
sympathetic hifeciion. Besides these cases a large number occur, the
causation of w’hich has been until recently, and, indeed, still is, more or
less obscure. Important discussions on these cases have recently
taken place at the Liverpool (1912) meeting of the British Medical
Association ; in connection wdth the series of discussions on alimentary
toxaemia at the Royal Society of Medicine (1913) ; and at the London
meeting of the International Medical Congress (1913). The following
are among the more practical outcomes ; —

1. Acute rheumatism is not a cause of iritis or uveitis. It is true
that ten years ago Poynton and Paine brought forward some experi-
mental evidence to the contrary, but this was admittedly extremely
inconclusive. As for any clinical evidence, as was pointed out by
Ormond,^ iritis undoubtedly occurs occasionally in those who have
had acute rheumatism at some pre\dous date ; but with two such
common diseases it has yet to be shown that the connection is anything
more than accidental.

2. Gonorrhoea is a very common cause of iritis. According to Lang,®
these cases generally occur in men where there is an infection of the
prostate arising from an uncured urethritis, which may linger for years
after the original infection.

3. Apart from syphilis and tubercle, by far the most common cause
of iritis, cyclitis, and choroiditis is septic absorption. To this many of
the cases formerly termed rheumatic are due, and it is this w^hich
accounts for the connection which undoubtedly exists in some cases
between iritis and rheumatoid arthritis, the latter also being due to the
common cause. Among the channels of septic absorption, the mouth
takes the first place. According to Lang, whose views on this subject
have been obtaining more general acceptance for many years past, the
most common source of infection of the uveal tract is pyorrhoea alveo-
laris. Out of 215 cases occurring in his private practice, in which sepsis
was diagnosed as the cause of ocular disease, in as many as 139 its

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mis, DISEASES OF

source was put dow'n as p}'orrhcea alveolaris, the next most common
cause being infection from the large gut, which accounted for 33 cases.
According to Lang, even mild cases of pyorrhoea alveolaris can cause
central choroiditis. “ Until the medical profession at large recognize
the importance of pyorrhcea and the gravity of leaving it untreated,
one cannot reasonably expect the dental branch of the profession to
do so either, especially as they are being taught to treat the mouth- in
a way that makes it impossible to avoid creating sepsis by putting on
crowns and building bars and bridges that cannot be kept clean. Until
this policy is reversed, and everything is done to enable the mouth to
be kept aseptic, loss of sight, and even total blindness, due to pyorrhoea,
will continue to occur.” Many cases of pyorrhcea no doubt go on for
years without any general septic infection resulting, because of the
protecting barrier by means of which the tissues are able to localize the
bacterial action. ” When this barrier has broken down, and the eyes
are affected by a serious inflammation which may destroy the sight, it
is too late to do anything except remove the teeth at once. Before the
extraction, the gums should be carefully cleaned and treated with anti-
septics. By doing so the amount of septic material that enters the
system through the large raw unprotected tooth sockets is greatly
reduced. Failing this precaution, the eye frequently becomes worse
immediately after the extractions. If the sight is to be restored in a
recent case of central choroiditis, the affected teeth must come out on
the chance that they are the cause, and if the inflammation does ng>t
subside, then other possible causes must be investigated.” (For
examples, see a paper by B. T, Lang.^)

4. There is some diSerence of opinion as to whether these cases are
due to the actual presence of micro-organisms in the eyeball, or merely
to their toxins. Fuchs says, ” In most cases, and especially in the
lighter ones, we have to do probably with the effect of toxins, while
some of the more serious' cases are perhaps of a parasitic nature.”'*
Ormond, on the other hand, doubts whether toxins alone are capable
of producing a localized inflammation of the u\*ea, and attributes all
serious cases to the direct action of micro-organisms.-^

Elsclinig, of Prague, believes firmly in the importance of auioAnioxi-
cation resulting from septic absorption from the intestinal tract as a cause
of uveitis, and relies largely on the presence of indican in the urine as
evidence of its existence ; but others consider that the importance of
this index has been over-rated. De Schweinitz'^ maintains that more
important evidence can be obtained by estimating the total percentage
of ammonia output. In summing up the matter, he says, ” There is
satisfactory evidence, clinical and bacteriological, that the majority
of cases of uveitis (iridocyclitis) are caused by micro-organisms or
their toxins. In this respect (omitting cases of syphilis, tubercle, and
sympathetic disease) the gonococcus and the staphylococcus are most
conspicuous. Other bacterial elements may doubtless play a similar
role.” . . . “ The primary source of infection from which the staphy-
lococcus proceeds and reaches the uveal tract, there to create an inflam-

mrs, DISEASES OF

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MEDICAL ANNUAL

mation, in all probability is most frequently a chronic septic process
in the mouth (pyorrhoea alveolaris), tonsils, nasopharynx, accessory
nasal sinuses, uterine cavity, skin (boils, furuncles, etc.),'" and gastro-
intestinal tract.

Treatment. — The main point is to remove the source of septic
absorption, whether situated in the mouth, bowel, or elsewhere, but
an important secondary measure is the employment of Vaccines.
Browming’ advocates the bacterial examination of the faeces in difficult
cases of iridoc5^clitis. In one instance he prepared a nearly pure
culture of pneumococcus from the faeces of a patient. A vaccine was
prepared, and the patient treated with it. The improvement was
immediate. The constipation, however, from which the patient was
suffering was treated at the same time. In another severe case of a
patient w'ho had had dysentery two years previously, an organism was
found in the faeces which proved to be a type of Flexner’s dysentery
bacillus. After the seventh injection of a vaccine made from it, the
eye which Avas least affected was reported to be well, but the case
subsequently relapsed.

References. — Med, Jour. 1912, ii, 1020 ; '^Proo. Roy. Soc. Med. vii.
No. 7, Supplemt. 301; Med. Jour. 1913. t 3S1 ; ^XVIIth Internat.

Congv. Med. Sect, ix, Pt. i, 5 ; ^Brit. Med. Jour. 1912, ii, 1020; ^XVIlth
Internat. Congv. Med. Sect, ix, Pt. i, 41 ; "^Proc. Roy. Soc. Med, vi. No. 7,
Supplemt, 330.

ISCHiEMIC MYOSITIS. {See Myositis.)

JAUNDICE IN CHILDREN. Frederick Langmead, M.D., F.R.C.P.

Catarrhal jaundice in children, as in adults, has usually been
attributed to gastro-duodenal catarrh, chill, or “ immoderate indulgence
at table.” Several epidemics, however, have been recorded, more
especially in recent years, which seem to denote that it may be infec-
tious in nature. Leonard Guthrie^ describes a small outbreak in a
limited district in West London. Ten cases w^ere seen in November
and Decembei*, 1911, and January, 1912 ; the child x'en’s ages varied
between three and eleven years. In tliree instances more than one
member of the same family were affected, and seven of the patients
were related as brothers and sisters.

The jaundice was deep in all cases, and associated with clay-coloured
stools and bilirubinuria. The average duration was three to four weeks,
but in one case it lasted only a week. It was ushered in by malaise,
languor, and sometimes drowsiness ; the temperature was usually raised
slightly. Anorexia was the rule, but in one case the appetite was said
to be voracious. Vomiting occurred in two cases, with diarrhoea in
one and constipation in another. In one case complaint was made of
itching. Bradycardia was not observ'ed in any case. The liver was
enlarged in six, and greatly so in four, extending nearly to the umbili-
cus ; when bile appeared in the stools it slowly subsided, and became
normal in size in from one to two weeks. The intervals which elapsed
between the onset of jaundice in different members of the same family

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JAUNDICE IN CHILDREN

could not always be determined accurately. None of the patients
were seriously ill at any time.

As Guthrie insists, it is important to distinguish between epidemic
“ catarrhal ” jaundice and the epidemic infectious jaundice usually
known as Weil’s disease. Icterus in the latter is associated with
urticaria, petechiae, haemorrhages from the nose, stomach, and else-
where, fever, enlargement of the spleen, nausea, vomiting, diarrhoea,
and albuminuria. Nervous S3’^mptoms, like those of acute ^^ellow
atroplty, ma}’’ end the scene. Relapses are common, and in some cases
a remarkable urinary' crisis attended by polyuria and excessive excretion
of urea takes place on the seventh or ninth day. Post mortem-, the
changes are those of acute y^ellow atrophy of the liver, or extreme
fatty degeneration, with diffuse hepatitis and leucocytic infiltration
near the portal spaces. It is essentially a filth disease, and is chiefly^
confined to the districts round the Mediterranean Sea. ' Guthrie thinks
it probable that epidemic jaundice, whether in the severe form known
as Weil’s disease or in its milder form called catarrhal jaundice,
epidemic or sporadic, consists of examples of acute diffuse hepatitis
produced by organisms or toxins which may’’ not be the same in all
cases. Blockage of the main duct may be secondary to hepatitis,
descending and not ascending the duct. The epidemics, although
mild in character hitherto, may at any time become more for-
midable.

Herrman® gives an account of a very similar condition, which he
styles acute- infectious jaundice.” His report is based on 98 cases,
25 of which were seen during October, November, and December, 1912,
and January, 1913. No patient was under one year old, and most
were between three and six. Over half were seen in the last three
months of the year. There w^as no evidence that the disease w’as due
to digestive disturbances. The syj-mptoms were very^ similar to those
in Guthrie's series, and, like that observer, he found a slow pulse
in none of his cases. The liver was palpably enlarged in 21 and
normal in only^ 4 of the last 25 cases examined. It diminished in
size wdth the decrease in the jaundice, but was still palpable when
this had disappeared. He adds one sign not recorded by Guthrie.
The spleen was palpable in 10 patients, not so in 15. It returned
to its normal size more quickly than the liver. All recovered,
except one, who developed symptoms resembling those of Weil's
disease, and died.

Treatment. — Herrman says that in many’’ cases it is only necessary
to Restrict the Amount of Fat in the Diet. Soup, lean meat, vege-
tables, skimmed milk, and bread may be given. Acting on the
assumption that the taking of food empties the gall-bladder, he
recommends frequent small meals. He gives five or six small meals
a day, the two or three additional ones consisting of a sandwich and a
glass of skimmed milk.

References. — ^Pyoc, Roy, Soc. Med. (Child, Sect.), 1912, Dec.;

Med. Jour. 1913. ii, 260.

KERATODERMIA BLENORR. 310 MEDICAL ANNUAL

KERATODERMIA BLENNORRHAGICA. E, Gyaham Little, M.D., F.R.C.P,

The hrst case of this rare condition to be reported in America is
contributed by Simpson, ^ who adds a convenient collection of the
other recorded cases. His patient, a man aged 28, had had gonorrhoeal
urethritis two years previously, with subsequent polyarthritis. Six
months later a rash developed, which became very chronic. It con*
sisted of two types of lesion, a crusted or scab-like brown " rupial
or conical mass which could be removed, leaving a smooth, pink,
slightly moist surface without ulceration ; these were distributed on
the legs, forehead, hands, and fingers. The second type of lesion was
a varioliform pustule, found chiefly on the wrists, internal malleoli,
and soles. The skin on the palms and the plantar surface of the feet
was enormously thickened ; the nails on fingers and toes were thickened,
showing a yellow discoloration, and were finally shed. Numerous
horn-like crusts were found on the scalp and on the internal borders
of the feet. The pustular lesions developed into the horn-like crusts,
which remained unchanged and, if removed, formed again.

Histological examination of a lesion from the leg showed marked
epithelial hypertrophy, inflammatory (polynuclear) infiltration of the
corium, with some plasma cells and hyaline changes in the connective
tissue. Repeated attempts to obtain gonococci from the blood and
the fluid in the joints, failed. The urethral discharge finally became
free from gonococci also. The patient remained bedridden in spite
of energetic treatment with Bier’s method, serums, vaccines, etc. ;
the skin improved with the use of Sulphur and Resorcin ointment,
but the patient committed suicide. Bacteriological examination of
fluids removed from the prostate, seminal vesicles, and ankle-joint
showed no organisms.

Another case reported by Swift,- in a man aged 35, is probabU^ the
first case to be met with in Australia. The description and behaviour
of the eruption reads very like the case reported above. Gonococci
were present in the urethral discharge during the appearance of the
eruption, but no organism could be identified in the scales of the
cutaneous lesion or in the blood. The arthritis proved extremely
intractable, but the skin improved with Formaldehyde Baths.

References. — -^Jouy. Amer. Med. Assoc. 1912, ii, 607; "^A'listral. J^Ied.
Gas. 1912, ii, 549.

KERATOSIS FOLLICULARIS (Daricr’s Disease).

E. Graham Little, M.D., F.R.C.P.

Mook^ reports four new cases occurring almost simultaneously in his
practice — probably a unique experience. The first patient, a male white,
aged 45, showed the characteristic eruption at the age of eight ^^ears ;
this spread at adult life to cover the head, face, neck and trunk, arms,
and forearms. There were granulomatous masses in the perineum.
The palms were thickened. There was general severe pruritus. The
second, a male white, aged iS years, had had the eruption for thirteen
years after an attack of measles. Eventually, the upper two-thirds of

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311

the body were aifected. The palms were thickened. In the third, a male
white, aged 21, the eruption appeared in early infancy, and persisted
through life until the upper half of the body was invaded. The
fourth patient was a male white, aged 24. The eruption had appeared
ten years previously, and when seen, the upper half of the body was
in\"olved. In all the cases treatment by X"rays produced great
improvement. Histological details of the four cases are added and
bear out the diagnosis.

Trimble^ has a singular series of five cases in one famil3r. An Amer-
ican woman, aged 63, was the first patient. She had had the disease for
twenty-five years, the scalp, forehead, temples, and legs being the chief
sites of the eruption ; there was much plantar hyperkeratosis. She had
three children, all of whom had the disease in typical form ; they were
respectively" a daughter, aged 41, and two sons, aged 38 and 36. The
daughter had a son, aged 14, who showed early but definite signs of the
disease. Histological examinations vrere made, and the typical " round
bodies,” formerly classed as psorosperms by Darier, were identified.
Diseased tissue was inoculated into the peritoneum of a guinea-pig,
a portion of diseased skin w’as grafted into the skin of a guinea-pig,
and the contents of diseased follicles inoculated into a rabbit : in all
cases with negative results. Cultural experiments with various media
gave an anaerobic growth on glucose agar with two varieties of bacilli,
one possibly B. acne. The other remained unidentified.

References. — '^Jour. Cut. Dis. 1912, 722; ^Joitr. Amer. Med, Assoc.
TQT2. ii, 604. ^

KIDNEY, SURGERY OF. {See also Pveutis in Children.)

J. IF. Thomson Walker, M.B., F.R.C.S.

Congenital Anomalies. — Tn an exhaustive article on the dystopic
kidney. S. C. Plumer^ records a personal case and adds 16 communicated
ones, which, with 67 collected by Straker in 1906, make a total of
84 clinical cases reviewed in his article. A dy^stopic or congenitally
displaced kidney is one which is abnormally?' situated in the body, never
having occupied its normal position. This differentiates it from a
movable or floating kidney, where the organ has become displaced from
its normal position. In dy^stopic kidney, the vascular supply is abnor-
mal, because it has adapted itself to the abnormal location of the kidney.
The shape is usually modified by its position on the promontory of the
sacrum, the sacro-iliac joint, or linea innominata, causing a depression
on its posterior surface. Furrows caused by vessels are also found,
and persistence of foetal lobulation has been noted. The origin of the
vessels is always from a point lower than the normal, namely, the lower
part of the aorta, the common or internal iliac, the middle sacral, or
the inferior mesenteric artery. The ureter is usually shorter, but the
ureteric orifices are normally placed in the bladder, even in crossed
dy"Stopia. The side affected in Straker ’s cases was : right, 19 ; left,
34 ; both, 2 ; supernumerary, 2. Defects in the genital organs, the
bladder, and the rectum, are frequently noted and, if unilateral, occur
on the same side as the misplaced kidney".

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MEDICAL ANNUAL

The kidney is usually normal, but may be the seat of hydronephrosis,
p3'onephrosis, calculus, sarcoma, tuberculosis, and cystic degeneration.
Common S3miptoms are pain in the lower abdomen, back, loins, but-
tocks, and lower limbs, a feeling of weight in the lower abdomen, and,
in the female, pain at the periods and on coitus. Constipation may
result from pressure on the rectum, or enuresis and vesical tenesmus
may predominate. The symptoms due to a pathological condition of
the displaced kidney are those special to each disease. In favourable
cases the diagnosis may be made by palpation of a normally-shaped
dystopic kidney. Failure to find a kidney in the normal position is of
no great value, and the finding of both kidneys in the normal position
does not exclude the possibility of a dystopic supernumerary kidney.
Catheterization of the ureters may show a considerable difference in
the lengths of the two ureters. Valuable information may be obtained
by the use of A'-rays to show the shadow of the kidney, and with an
opaque bougie in the ureters, to show these tubes. Munro found pulsa-
tion of the trigone due to an underlying renal artery.

The treatment of normal dystopic kidney is summed up as follows :
No operative interference unless the symptoms are of considerable
severit3^ If an ovarian cyst or a pyosalpinx is present, this is removed,
leaving the kidney. If operation on the kidney is required. Dislocation
and Reimplantation in a part where it is not a mechanical hindrance
should be selected. Where nephrectomy is not inevitable from the
first, the kidney tissue and vessels should be carefully preserved.
In a normal dystopic kidney, ventral laparotomy is the best method of
operative approach. In parturition, delivery, although often prolonged
and difficult, can take place in the majority of cases without operative
interference.

Straker summarizes the management of dystopic kidney in pregnancy
and parturition as follows : — If discovered at the beginning of pregnancy ;
laparotomy, dislocation, fixation. If discovered later: consider the
advisability of the induction of premature labour. A normal dystopic
kidney should not be removed shortly before or during labour. If
discovered during labour, a pathological kidney may be punctured to
allow delivery ; nephrectomy to be done after the puerperium. If
during parturition, delivery cannot take place without injury to mother
and child, in case of a dead child perform craniotomy, or, in case of a
living child. Caesarean section, or an operation to widen the pelvis.

Charles H. Mayo^ discusses the surgery of single and horseshoe kidney.
In 36 cases of gross renal and ureteral anomalies observed during five
37^ears in the Ma}^© clinic, 7 were found incident to other abdominal
operations. Among the total number were 12 of the horseshoe type and
6 of the congenitally, single, or asymmetrical type. During this period,
649 operations were made on kidneys and ureters. There was an
average of one serious anomaly associated with the disease in every
26 cases, thus showing that such anomalies are often the cause of, or a
contributing factor to, disease of' the kidney. A heavy band of renal
tissue forming a horseshoe kidne}^, gives rise to pain in the abdomen and

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313

KIDNEY SUROERY

lumbar region and beneath the epigastrium. The pains, which radiate
downwards, are present when the patient is upright, and disappear on
resting. These patients suffer severely from jarring and on muscular
effort. Throbbing and a sense of pressure in the abdomen may occur,
and on bending backward the discomfort is greatly increased. Such
kidneys are more liable to injury, compression of the abdominal vessels
may occur, and a case of thrombosis of the iliac and femoral veins
causing oedema of the legs and ascites is reported by Neufville. In the
diagnosis of horseshoe kidney, the associated anomalies of the genital
system should be noted. Pyelography is of great assistance, and is
more accurate than the opaque ureteral catheter. In every case w'here
the diagnosis is not certain, the other kidney should be explored, usually
through a separate incision, before removal of a tumour or a diseased
kidney ; and in abdominal surgery in which tumours of unknowni type
and origin are discovered, regardless of location, the kidneys should be
palpated before the removal of the tumour.

An account of a dumh-hell kidney, a rare variety of horseshoe kidney,
found on attempting nephrectom}? on a cadaver, is given by Herman
and Fetterolf.'^ The specimen consisted of two lateral masses of kidney
substance with a connecting bar of the same tissue. The malformed
kidney occupied the normal renal position. There were seven renal
arteries, four from the aorta, one from each common iliac artery, and
one from the left spermatic artery. The renal veins numbered three
on each side.

Movable Kidney, — C. MacLaurin^ formulates the following conclu-
sions. Nephroptosis is almost always congenital, and is comparatively
rarely associated with general splanchnoptosis. The right kidney is
more or less movable in a large percentage of women. Nephroptosis
is liable to be followed by appendicitis, which is found in about one-
third of cases of movable kidney. “ This in turn may lead to pelvic
trouble and gastric ulcer or chronic dyspepsia." The symptoms are
due to dragging of the kidney, to torsion of the pedicle, or to resulting
appendicitis. Nervous s^anptoms are probably the result of continued
dyspepsia, pain, and discomfort. General splanchnoptosis does not
require operation. All cases of abnormal mobility of the kidney wdth
this exception will probably require Nephropexy sooner or later.
Appendicectomy should be done in every case. Pyuria and albumi-
nuria do not contraindicate operation, but render it imperative. The
best operation is the shelf method. The author has performed it in
sixty-seven cases wdth no mortality, and he does not know of any case
of relapse.

A. Werelius® describes a " basket-handle " operation for nephro-
ptosis. The capsule is split along the convex border, and stripped
halfway from the anterior and posterior surfaces. The posterior free
flap of capsule is detached above and laterally, leaving only its attach-
ment to the lower pole, and the anterior flap of capsule is treated
similarly and left attached to the upper pole. These " suspensory
ligaments " are drawn " through the muscles and fascia on either side

KIDNEY SURGERY

314

MEDICAL ANNUAL

of the wound/’ The ends of the ligaments ” are tied in a knot and
transfixed by a silk or catgut suture. The united flaps thus form a
‘‘ basket handle ” by which the kidney is suspended.

J. Lacy Firth® advocates the method of nephropexy used by Billing-
ton, and warns against the danger of injuring the pleura. One advan-
tage of this method is that the kidney is fixed at a normal level. The
writer admits, however, that he has only seen one case where trouble
was due to too lo\v fixation, and of this case he says : " I cannot be at
ail certain that this patient’s pain was due to the low position of the
kidney.” The following are the steps of the operation : Oblique
incision commencing over the eleventh intercostal space ; separation
of the fat and perinephritic fascia, dislocation of the kidney, and
separation of all adhesions and fat ; deflection of a flap of renal
capsule downwards from the upper half of the kidney, two-thirds of
the flap being from the posterior surface, and one-third from the
anterior ; insertion of two supporting subcapsular sutures into the
lower half of the kidney, the ends of these being sufficiently long to
pass through the muscles and skin above the wound, and to be
tied over gauze rolls ; passage of a curved Spencer Wells’ forceps
through the eleventh intercostal space at the edge of the erector spinae,
drawing the capsular flap through the opening above the twelfth rib,
turning it down, and suturing it to the unstripped surface of the kidney
at the lower border of the last rib.

The method did not originate with Billington. “ Methods and
principles suggested by Edebohls, Fullerton, Goelet, and Brodel have
been combined in the operation, and the combination of methods
adopted .seems to have been first used by Jordan Lloyd.” The most
serious drawback to this operation according to Firth, is the danger
of wounding the pleura. In ten cases this accident occun-ed once, and
was followed by pneumothorax with serious symptoms but ultimate
recovery.

Nephrolithiasis. — F. S. Watson’ discusses the reports of 100 cases
of renal calculi, jo cases of ureteral calculi, and 10 cases simulating
renal calculi. In really expert hands, he considers radiography a very
certain diagnostic test. In any but the hands of the best experts it is
unreliable. In the 10 cases which closely simulated renal calculus,
but where calculus was absent, the conditions present were as follows :
displaced kidney constricted by bands of adhesions, pressure of adhe-
sions in a normally-placed kidney, movable kidney not detected prior
to operation, distention of the renal pelvis due to misplaced ureteral
outlet, acute congestion of the kidney, constriction of the ureter due to
adhesions. In one case no cause could be found in the kidney. The
dangers of leaving a stone in the kidney are destruction of the renal
tissue by pressure, tendency to infection from the presence of the stone,
and, in bilateral calculi, the occurrence of obstructive anuria. As a
rule, anuria occurs from the blocking of one kidney where the other is
absent or seriously diseased. In a small number of cases there is a
kidney on the unobstructed side which has ” a useful degree of fiinc-

NEW TREATMENT 315 * KJDNEY SURGERY

tional capability if it can be restored to its previous activity.” When
this is the case, the suspension of the function of the second kidney is
due to reflex inhibition from blocking of the opposite ureter.

In the treatment of venal colic the author considers that it is better
to abolish the pain by means of the combined use of Ether and Morphia,
than by morphia alone. Doses of morphia, he says, which are suffi-
ciently large to control a severe attack of renal colic ” are likely to
prove poisonous if the pain — as it so often does — suddenly ceases.”
On the other hand, if ether is given to the point of primary anaesthesia,
and at the height of the spasms of pain only, neither the drug nor the
ansesthetic is harmful or dangerous. Thus, of morphia, \ gr. subcutan-
eously is usually sufficient when primary anaesthesia is given in the
worst times of the pain. With a view to causing expulsion of the stone,
the writer recommends the administration of Spirits of Turpentine in
lo-min. doses in capsule, and the patient is put on a milk diet with
fish and dry toast once daily. Each tumbler of milk should be diluted
one-quarter part with Vais water ; the milk should be swallowed slowl}^
and should be slightly warmed. Turpentine should be given for six
days, then omitted for two da^^s, and resumed for six days more, if
required. The patient is directed to drink a large quantity of water
during the treatment, and is kept entirely quiet during each course of
six days. In suitable cases, the treatment was successful in about
87 per cent. The average length of time before the calculus was
passed in the successful cases was eleven days.

In discussing the surgical treatment of calculous anuria, the author
holds that simultaneous Bilateral Nephrolithotomy should be per-
formed when there are calculi in both kidneys. Wdien dealing with
unilateral renal calculus, and the kidney exposed is found to contain
no calculus, but to be diseased, so that it is judged that its function
alone would be insufficient to sustain life, the surgeon should at once
cut down and remove the stone from the second kidney.

In an interesting article on Pyelotomy for stone, Eisendrath® gives
the following notes in regard to the role played by the A'-rays. If the
patient has been thoroughly prepared, and the plates are examined by
one accustomed to interpret them, one can determine with more than
a fair degree of accuracy the position of shadows with reference to
whether they are in the renal pelvis or parenchyma. A shadow
located on a level with, and close to, the transverse process of either
the first or second lumbar vertebra, is due, as a rule, to a calculus
located -at the junction of the ureter with the renal pelvis. Such a
shadow may be triangular or round, or may show a dowmward and
inward projection. Zuckerkandl has recently directed attention to
the characteristic nipple-like appearance of shadows at the uretero-
pelvic junction. When a shadow of this shape and location is present,
one can usually say in advance that the calculus can be removed by
pyelotomy, Wheit the kidney lies unusually low or high, however, the
shadow may be due to a calculus in the upper or lower half of the renal
pelvis respectively. In the absence of other complications, pyelotomy

MEDICAL ANNUAL

KIDNEY SURGERY • 316

can be considered as the ideal method for calculi at the ureteropelvic
junction.

When the shadow is further out from the ends of the transverse
processes of the first or second lumbar vertebra, the calculus usually lies
in a dilated renal calix or in the renal parenchyma. If the shadows
are multiple and close together, the stones are probably in the renal
pelvis or in a dilated calyx readily reached through a pyelotomy
incision. When the shadow is single and a little further out than where
the ureteropelvic-j unction calculi are seen, the calculus is usually free
in the renal pelvis or lodged in a primary or secondary calix, and easily
reached through a pyelotomy incision. When the shadow is large and
triangular or coral-like, or there are a number of shadows distributed
over a wide. area, one of two conditions is usually found at operation :
either the renal pelvis is greatly dilated and filled by a large calculus,
or multiple shadows signify considerable distention of the renal paren-
chyma. With such .r-ray findings,^ pyelotomy can scarcely be con-
sidered.

In regard to the technique of pyelotomy, the author notes that it
must be possible either to lay the kidney completely on its anterior
surface on the skin edges of the incision, or at least to gain access to the
posterior aspect of the renal pelvis without much tension on the renal
vessels. If the pedicle is short, or there is much fixation of the kidney
by adhesions, pyelotomy is out of the question, and too much traction
under such conditions would surely result in disaster. In the majority
of cases, however, p3?elotomy is possible if the incision is not too small,
and the wound edges are well retracted. That accidents can occur
when a calculus is firmly impacted in a calyx is shown by a case of the
author’s, in which severe haemorrhage followed extraction of such a
calculus, and necessitated nephrectomy. The haemorrhage was found
to proceed from a vein just outside the renal pelvis in close contact
with the calculus.

Two cases of nephrolithotomy in young children are recorded and
discussed by R. Ollerenshaw.^ Renal pain in children is referred to
the abdomen, and so ascribed to gastro -intestinal disturbance. The
pain may also be referred to the hip or spine, and simulate disease in
these regions. It is frequently referred to the groin, and is accom-
panied by retraction of the testicles more often in boys than in men.
Calculi may cause no symptoms in children. Haematuria is the most
constant and reliable symptom. Nocturnal incontinence sometimes
results from fine uric acid sand.

Daniel Eisendrath^” states that bilateral urinary calculi usually
produce one of the following clinical pictures : (i) The ordinary

calculus (ureteral or renal) S3^mptoms are present on one side, but radio-
graphs show calculi on both sides ; (2) Pain or other symptoms are
manifest alternatel}^ on one side or the other, and radiographs show
calculi on both sides ; (3) There are definite symptoms of calculus

simultaneously on both sides (comparative!}^ rare) ; (4) The case is seen
either during an attack of calculous anuria, or giving the history of

NEW TREATMENT

3t7

KIDNEY SURGERY

transitory attacks ol anuria with calculus symptoms in the intervals.
The well-known clinical fact that the pain may be referred to the side
opposite to the renal calculi must be remembered in the first three
groups- For practical purposes the author divides cases of bilateral
calculi into those presenting the familiar symptoms of renal or ureteral
calculi, and those seen during an attack of calculous anuria. The
majority of surgeons do not agree with the view of Kummell, that anuria
is rarely due to reflex inhibition of one kidney when the opposite ureter
is blocked with calculus. Calculous anuria is more likely to develop
in cases of bilateral calculi than in unilateral cases, and there is a
greater tendency for bilateral calculi to recover after removal.

The question of Operation varies according to whether the patient
is seen during an attack of anuria or not. When anuria is not present,
there is considerable difference of opinion as to whether the calculi
should be removed at one sitting or at intervals of four or six weeks.
The majority of surgeons believe that it is best to operate upon the
worst side first, and then to operate on the other side six or eight
weeks later. The worst side is determined by ureteral catheterization
and the functional tests. The author holds that the calculi should be
removed from both kidneys at one sitting under' certain conditions-
He operates first on the side that gave the last symptoms. If this
kidney is found to be insufficient to maintain life, the second kidney is
operated on at once ; if, however, the first kidney is in good condition,
he operates on the second side after an interval. ‘‘ The question of
nephrectomy,'" Eisendrath says, “ depends entirely upon whether the
opposite kidney is functionally incapacitated or not, and whether its
ureter is likely to be blocked or not, following the -removal of the
worst kidney." In calculous anuria the side chosen should be that
on which there is an enlarged tender kidney, and if the calculus of
tliis side appears to be the cause of the anuria, further operation on
the second kidney should be deferred to a later time. If, however, the
first kidney is found to be widely destroyed, it is best to operate on the
second kidney at once.

Renal Tuberculosis . — At the Medical Society of London, Ealph
Thompson^^ made a communication based upon 13,005 autopsies,
82 iS on males and 5287 on females, at three London hospitals.
Solitary kidney occurred in i in 587 autopsies. In ascending inflamma-
tion of the kidneys, the disease was bilateral in 135 and unilateral in
38. A series of cases was related where there was evidence of tuber-
culous peritonitis and abdominal lymphadenitis leading to pressure
on the ureters. Sufficient attention had not been paid to constriction
of the ureters by fibrous bands formed as a result of tuberculous
peritonitis. In tuberculosis of the kidney, the author found that the
unilateral cases of post-mortem renal tuberculosis were as 37 to 74
bilateral. In the unilateral cases, the right was affected in the pro-
portion of 13 to 5 on the left. The explanation of the greater frequency
with which the right side was affected was to be found in the arrange-
ment of the blood-vessels, the anatomy of the colon, and the normal

KIDNEY SURGERY 31S MEDICAL ANNUAL

anatomical obstruction which might be present to the flow of urine
along the ureter.

Discussing this communication, Thomson Walker referred to sta-
tistics relating to the unilateral or bilateral distribution of tuberculosis
of the kidney. Post-mortem records had the great disadvantage
that they referred only to the final stage of the disease, and in this
stage tuberculosis was bilateral in from 35 to 60 per cent of cases. The
surgeon was concerned wdth ante-mortem pathology?-, and here tubercu-
losis of the kidney w^as unilateral in from 88 to 92 per cent of cases
that came under observation. The only reliable method of diagnosis of
the unilateral distribution, was the ureteral catheter. In cases where the
bladder was diseased, and it was impossible for an experienced cysto-
scopist to catheterize the ureters, a course of tuberculin sometimes caused
improvement in the bladder condition, enabling the examination to
be carried out Wliere this failed, the bladder might be opened supra-
pubically and the ureters catheterized, but this was not an easy pro-
ceeding when the bladder was tuberculous. The most satisfactory
method in such a difficulty was to expose the supposed healthy kidney
and examine it by nephrotomy, and at a later date to operate on the
diseased kidney.

Tumours. — R. H. Jocelyn SAvan^^ describes a case where a large
hypernephroma of the right kidney could not be felt owing to the fact
that the anterior border of the liver descended to a hand’s breadth
below the costal margin. On operation, it was found that the renal
growth had pushed the liver forwards and downwards, rotating it
upon a horizontal axis. The points of difference in the symptoms of
hypernephroma - and other tumours of the kidney were as follows :
Hypernephroma is most common betAveen the ages of fifty and seventy,
and is of comparatively sIoav growth ; sarcoma is more common in
childhood, and forms a rapidly growing tumour with early cachexia.
Carcinoma is a disease of later life, and gi\^es rise to more pain, and
usually to constant haematuria ; Avhereas in sarcoma, hematuria may be
absent, and in hypernephroma is usually of an intermittent type.
Glandular enlargement is more common in carcinoma, either about
the kidney or in distant glands, AA^hereas a pulmonary or osseous
deposit is more usual with hypernephroma. Carcinoma and sarcoma
tend to infiltrate the surrounding tissues more rapidly than hyper-
nephroma, so that the resulting tumour of the kidney may be more
fixed. Embryonic groAvths are more common in early life, and usually
form a rapidly groAving tumour of the kidney. Pain and haematuria
are infrequent, but a marked feature of these growths is to cause
symptoms by pressure upon other organs. Thus oedema of the legs,
or eA*en ascites, Avith enlargement of the superficial abdominal veins,
jaundice, or dyspnoea, may be present. With tumours of the renal
pelvis, haematuria is marked. The symptoms may be spread over a
number of years in the papillomatous growths. The renal tumour may
vary in size if the ureter becomes blocked by growth or clot.
Cystoscopic examination may reveal small secondary villous tufts in
the bladder near the ureteric orifice.

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KIDNEY SURGERY

Early Hydronephrosis, — H. Cabot^“ regards the following two causes
as standing out pre-eminently in the production of this condition :
(i) Mobility of the kidney without corresponding mobility of the
upper portion of the ureter ; (2) Abnormal renal vessels passing to
the lower pole of the kidney. The symptoms in early cases are divided
into three groups : those suggesting stone in the kidney, attacks of
renal colic, a few blood corpuscles and a trace of albumin in the urine ;
similar symptoms, but without abnormality in the urine ; and those
resembling acute infection of the kidney, but with a persistently sterile
urine. Catheterization of the ureter, with distention of the renal
pelvis, gives some help, but is only reliable when there is considerable
dilatation, and fails to reveal the cases with an irritable and therefore
apparently contracted pelvis. By itself, A'-ray examination has only
a negative value in excluding renal calculus and helping to exclude
renal tuberculosis. Pyelography is the mainstay of diagnosis {see
Medical Annual, 1912, p. 363).

Acute Kmnatogenoiis Infection of the Kidney , — Lucius W. Hotchkiss^*^
records two cases of excision of an infarct. At operation the kidney was
found to contain a triangular area of soft white infarction, apparently
riddled with minute abscesses. As the rest of the organ appeared
healthy, and the infected portion of the cortex was easily enucleable
with the finger, the infarct was extirpated in this manner. There was
little bleeding. In one case the edges of the gap were brought together
by means of catgut sutures, and in the other by gauze pads placed
above and below the organ. The operation, the author believes,
has a limited sphere of usefulness.

Operations on the Kidney. — ^Baldwin and Baldwin^® have in ten years
performed nephrectomy 67 times, with a mortality of 25 per cent.
There were 34 nephrectomies for tuberculosis, with a primary mortality
of 20 per cent ; only 6 of the survivors have died since. The authors
hold that nephrectoni}' with complete recovery “ does not greatly
shorten the expectancy of life,” Nephropexy was performed in 61
cases ; late results were given in 54 of these, with complete success in
45, great improvement in 4, and complete failure in 5, The Baldwin
operation was used, two haps of the kidney capsule being stitched to a
column of muscle derived usually from the edge of the quadratus
lumborum. Decapsulation of the kidney for chronic nephritis, ” in
the only case where it was given a fair trial, proved a brilliant success ;
in four other last-resort cases it failed to do any permanent good,
although it did not hurry the demise.”

Andrew Fullerton^® discusses a series of 48 cases of nephrectomy
with 4 deaths. The fatal results were due to sepsis, shock, and anuria.
He insists upon the necessity for accurate diagnosis before any opera-
tion on the kidney is undertaken. In one case of calculous disease
the author removed the only functionating kidney. - The patient died
of anuria on the ninth day after the operation. The second kidney
was a large cyst which did not communicate with the ureter. This
result .would have been avoided had the ureters been catheterized

KiDNev SURGERY

320

MEDICAL ANNUAL

pre\ious to operation. A case is quoted to show that the painful
kidney may not be the one at fault. The author strongly deprecates
the removal of a kidney which is bleeding, if no obvious disease can
be found in it on exploration. The mortality of nephrectomy has
diminished in recent years owing to the more efficient means of early
diagnosis, and especially to the more accurate information obtainable
by means of the ureteral catheter. In most cases of unilateral disease
of the kidneys, the urine of the affected side will be found to have a
diminished specific gravity. In advanced cases, ropes of inspissated
pus or blood may replace the fluid efflux. It is not good surgery to
remove a diseased kidney until satisfactory evidence has been obtained
as to the functional capacity of its fellow. If the urine of the pre-
sumably sound kidney has a specific gravity of 1015 or over, is passed
in sufficient quantity, and is free from albumin, pus, and blood, it is
reasonably safe to remove the affected organ. A trace of albumin, or a
few pus- or blood-cells in the urine from the presumably sound side,
provided the specific gravity is not too low, need not necessarily
preclude operation, other conditions being favourable. The accidents
that are liable to occur during the operation of lumbar nephrectomy
are, haemorrhage from difficulty in securing the pedicle, or from injury
to the vena cava, injury to the pleura or peritoneum, interference with
the blood -supply of the colon leading later to faecal fistula, and laceration
or complete removal of the suprarenal body when adherent to the
kidney.

In the Medical Annual of 1912 reference was made to the in-
vestigations of Moore and Corbett in regard to the damage done to
the kidney by operations. In a further contribution, these authors^’
submit some interesting points in regard to several methods of sutur-
ing the kidney. The damage done by incision and that done by
subsequent suture comprise two distinct types of trauma. In the first
class are lesions resulting from the anaemia produced by section of the
blood-vessels. These consist of small anaemic infarcts, the shape and
size depending upon the distribution of the severed blood-vessels.
The damage done by the suture is usually much more extensive and
very much more erratic, and may vary from a very little scar tissue
to the late destruction of the entire kidney. One of the unfortunate
results of applying ligatures is the strangulation of small pieces of
kidney parenchyma, particularly in the pyramids. Such strangulated
material may become calcified, and later on form the basis for a calcium-
phosphate stone. The infarcts resulting from a strangulation of tissue
undergo cicatrization, and the ultimate scar may be comparatively
insignificant. Much of the parenchyma is lost, but it ma}^ be restored
by compensatory hypertrophy.

Cullen advocated the use of a silver wire to tear through the kidney
parenchyma, instead of cutting with a knife. The authors state that
this method has not met with the good results in their hands that
have been described. The objections they raise to the silver wire
method are : (i) Difficult}’ in locating the bloodless zone of the kidney ;

NEW TREATMENT

321

KNEE INJURIES

{2) Danger from hsemorrliage from irregular aberrant vessels ; (3) The
method necessitates the cutting of a number of collecting tubules and
other kidney structures ; (4) The wire traumatizes and is difficult to
control. With the wire method the infarcts were sometimes very
irregular, and in one case nearly one-fifth of the kidney suffered
destruction. In experimental work, the method accompanied by the
least amount of haemorrhage and comparatively little post-operative
destruction of tissues, consisted in clamping the renal vessels with a
Carrel soft- jawed forceps, and approximating the renal parenchyma
after exploration by through-and-through sutures of very fine silk.
Experiments were undertaken to ascertain whether temporary cutting
off the blood-supply of the whole kidney by the clamp caused damage.
It was found that, after one hour’s atresia, degenerative lesions of the
epithelium could be found three days later ; but these had disappeared
entirely at the end of six days.

In an article on post-operative renal injection, H. D. Furniss^® refers
to cases in which there has never been any catheterization of the
bladder, antecedent cystitis, or previous infection of the urinary
system. He holds that renal infections are more apt to occur when
there has been some operation on the intestinal canal, or wffien there
is a wound which is contaminated by intestinal contents. He suggests
the possibility that the constipation incident to post-operative
intestinal peristalsis and the purging used to overcome this, may
account for some of these cases. The most common path of infection
is by the blood-stream. The late occurrence of the infection, and the
fact that most of the patients have had some rise in temperature
immediately following operation, lend weight to the theory that the
origin of the infection is from thrombi at the seat of the operation.

References. — Gyn. mid Ohst, 1913, i, i ; ^Ann, Stirg. 1913, i, 511 ;
^Ibid. 868; ^AnsiraL Med. Gaz. 1913, 191; '^Jour. Amer. Med. A'isoc. 1913,
1, 643; Med.-Chir. Jour. 1913, 220; "Bosi. Med. and Surg. Jour.

1913, i, 37 ; ^Jcur. Awer. Med. Assoc. 1913, i, 1145 ; ^Brit. Med. Jour. 3913,

i, 112 ; '^^Surg. Gyn. and Ohst. 1913, ii, 21S ; '^^Bv'ii. Med. Jour. 1913, i, 4.15 ,
^^La7i(et, 1913,1.374; ^^Jour. Amer, Med. Assoc. 1913, 1, 16; '^^Ann. Surg.
1913, ii, 226; ^^Surg. Gyn. and Ohst. 1913, i. 315 (abstr.) ; ^'*Brit. Jour.
Surg. 1913, Oct., 211 ; ^'^Lancet, 1913, i, 37.^ ; ^’^Jour. Ayncv. Med, Assoc. 191 j,

ii. 95 7 •

KNEE, INJURIES TO. [See also Fractures.)

Priestley Leech, M.D., F.R.C.S.

Rupture of the Crucial Ligaments. Fractures oj the Spine oj the
Tibia. — R. Jones, of Liverpool, and Alwyn Smith, ^ of Winnipeg, say
that fractures of the spine of the tibia are much more frequent than is
believed, and often associated with rupture of one or other of the
crucial ligaments. Hogarth Pringle thought that excessive traction
on the anterior crucial ligament, produced fracture of the spine of the
tibia ; but these authors think that though this is true of some cases,
in others the chip of bone detached does not include the area to which
the anterior ligament is attached.

The points to remember about the mechanism of the crucial ligaments

KNEE INJURIES 3>2 MEDICAL A>JNUAL

are as follows : (i) The anterior ligament is tense when the knee is
fully extended, and prevents the tibia from being displaced forwards
on the femur. (2) The posterior ligament is tense in complete flexion,
and prevents the tibia from being displaced backwards on the femur.
(3) Both ligaments check inward rotation of the tibia.

If after an injury to the knee, the tibia can be displaced backwards
or forwards, or rotated in^wards in the extended position, an injury of
one or both crucial ligaments may be diagnosed. If in the extended
position the tibia cannot be displaced fonvards, the anterior crucial
ligament is not ruptured ; if in full flexion the tibia cannot be displaced
backwards, the posterior crucial ligament is presumably not ruptured.
The most constant sign of fracture of the spine of the tibia is an
obstruction to full extension ; the block feels like a definite bony
obstruction, and is quite different from the locking which occurs when
a dislocated semilunar cartilage is nipped.

Jones and Smith divide these injuries into three classes.

1. Avulsion of the Tihial Spine or of its Internal Tubercle is the only
type of fracture of the spine which has been previously described. It
is produced by violent traction on the crucial ligaments : a mechanism
similar to that which produces their rupture, to cause -which great
violence is necessary. Rupture of the posterior ligament alone is a rare
accident. Pagenstecher describes one case. Firm union of the torn liga-
ments is usually obtained if the limb is kept at rest for a long period.

2. Fracture of the External Tubercle of the Tibial Spine has not been
described previously ; it has been seen in three of their cases in the last
few years, and they do not think it is connected with injury to the
crucial ligaments. The fragment of bone broken off is very small, and
is not in the region to which either of the ligaments is attached. They
believe the tip of the external tubercle is shorn off from behind by the
inner sharp margin of the external condyle, either by the femur being
forced forwards or the tibia being driven backwards. The height of
this spine varies greatly in different individuals, and it is the high one
which is liable to this injury. The mechanism of production is the
same as that of dislocation of the internal semilunar cartilage.

They describe two cases of

3. Injury to the Spine combined with Fracture of the Tibial Tuberosities.
In one the external tubercle was fractured as well as the internal
tuberosity ; in the other case the exact opposite occurred.

Treatment. — ^The authors are very emphatic, and remembering
the present views on the surgery of joints, their views deserve serious
consideration. Injured ligaments require four or five weeks for their
repair, and any elongation or laxity which may be allowed to remain
means functional disability. For accurate repair of tendon or ligament,
no strain should be thrown upon th^m during the period of healing.
The practitioner must learn that nothing but teinporar3?' stiffness
follows even prolonged rest of a joint. There would be few recurring
displacements of the semilunars if the first injury were efficiently
treated by resting the injured structures, more particularly^the internal

NEW TREATMENT

3^3

LABOUR

lateral ligament. The nipture of any ligaments of the knee should be
treated by absolute rest until healing is complete, and this particularly
applies to the crucial ligaments. In a recent rupture of the crucials,
fixation of the knee for three to six months offers the best chance of
recoverj^ In neglected cases, where movement has been allowed
earl}’, they also think fixation of the joint should be first tried ; it
should be continuous, not even a momentaiy relaxation being allowed.
In old cases, the choice should lie between an operation for fixing the
crucials, a mechanical support allowing flexion, or arthrodesis of the
joint. If suture is performed, the capsule and ligaments should be
made tense by reefing, as it is unreasonable to expect imperfectly
repaired crucials to bear the
great leverage to which they
would be subjected in the pres-
ence of a lax capsule and lateral
ligament.

In fractures of the tibial spine,
the knee should be manipulated
until full extension is secured ;
and if there be no sign of laxity
of the joint due to injury to the
crucials or other ligaments, the
fixation need not exceed two
months. When full extension is
not possible, and disability,
whether pain, stiffness, or effu-
sion, exists in addition, operation
is to be recommended.

The technique recommended
for the operation is as follows :

The knee is flexed over the table
at almost a right angle ; a ver-
tical incision starts an inch above
the patella, extending almost to the tubercle of the tibia. The patella
is sawn vertically and its ligament split. The segments of the patella
are separated to the border of the cond^des. The fat behind the
patella is removed, when an excellent view of the spine and anterior
crucial is obtained. Any obstructive mass is removed, the knee is
straightened, and the ligament of the patella, the aponeurosis, and
the extensor are stitched {Fig. 38).

Reference. — Jour. Surg, 1913, July, 70.

LABOUR. Victor Bonney, M.S., M.D., B.Sc., F.R.C.S.

Bryden Glendining, M.S., F.R.C.S.

. Sequelis. — Solomons,^ as a result of examining 543 primiparae six-
teen days after labour, found that 40 per cent only were quite normal.
Cervical laceration after normal labour is very common, 264 (or 48 per
cent) having a tear of over one-third of an inch. He suggests immediate

. 3S. — Aj femur; Bj tibia; C, transveisc

ligament; D, anterior crucial ligament; F.
posterior crucial ligament ; F, F' , cut halves
of patella.

LABOUR

324

MEDICAL ANNUAL

suture if there is bleeding from the tear ; if there is no haemorrhage,
suture after two months ; or a routine examination at the end of child-
bearing in all women, when all lacerated cervices should be repaired.
Post-partum retroversion, when not caused by inflammation, is due
to the dorsal decubitus ; and the best treatment is therefore postural.
Every patient should be examined a month after labour for this compli-
cation ; Solomons found it in 9 per cent of his cases. Non-union of a
stitched perineum was found in 5 per cent ; he advises an immediate
second perineorrhaphy in all aseptic cases. No definite rule can be
made about early rising in the puerperium as a proph^dactic against
pulmonary embolism until more statistics have been published. He
advises free movement and gymnastic exercises from the beginning,
the patient to get up from the twelfth to the fourteenth day.

Obstructed Labour, — Stellwagon^ considers the operation of Caesarean
Section in experienced hands simple and harmless when performed at
the time of election and not as an emergency. He thinks that the
field for this operation is enlarging, and it is therefore important that
its high mortality-rate in cases of emergency should be averted by the
obstetrician making an early decision as to treatment. The risk of the
operation increases proportionately to the severity of the previous
manipulations.

Jeannin® describes the technique of abdominal Caesarean section as
usually performed in France. The incision in the abdominal wall is
ten to twelve inches long. The uterus is eventrated, and then opened
by a longitudinal incision of six to eight inches on the anterior wall of
the uterus which does not touch the lower segment. The uterine wall
is stitched up on one layer with silk sutures which do not include the
mucous membrane. The abdominal wall is closed in layers, and no
drainage is used.

Maxwell^ describes four cases of Caesarean section which had to be
undertaken for what are always regarded as rare indications : one for
malposition of the uterus due to previous ventrofixation and causing
dystocia, one for central placenta prsevia at the thirtieth week of
pregnancy, and two for obstruction due to uterine fibroids. In both
of these latter cases subtotal hysterectomy was performed. All the
mothers and two children did well; one child at the thirtieth week
dying in a few days, and another dying when ten days old as the result
of a bum. He prefers abdominal to vaginal Caesarean section ; he
does not eventrate the uterus before delivering the child, and considers
that the earlier in labour the operation is done, the smaller is the
mortality, owing to diminished risk of sepsis.

Schwarz® reports a case of rupture of a pregnant uterus on which
classical Caesarean section had been performed three and a half years
before for severe eclampsia at the eighth month of pregnancy. The
uterus was opened by the transverse fundal incision, which wais sutured
with interrupted catgut sutures. Both mother and child did well.
At the second operation the abdomen was opened, and the child and
placenta were found in the abdominal cavity. The uterus was firmly

NEW TREATMENT

325

LABYRINTHITIS

contracted, the rupture extending through the old incision from one
tubal pole to the other. Subtotal hysterectomy was performed, and
the patient did well.

Savage® describes three cases of Pubiotomy, and discusses its limita-
tions. He considers that it should only be performed when the child
is alive and likely to live ; in cases where the pelvic contraction is only
moderate, the true conjugate measuring from 3 to 3I inches ; after
trial of forceps with the patient in Walcher’s position, and when the
patient is free from infection. Wallace’ describes two cases, and
discusses the merits of the operation. He considers that it should only
be done where the addition of an extra f inch to the conjugate will
render delivery easy, where there is no suspicion of infection, and the
child is presenting by the head. It should not be regarded as a rival
to induction of labour. Caesarean section, and craniotomy, but should
be confined to the limits mentioned above.

Clihord White’ describes three cases of dystocia due to a contraction
ring, discusses the condition, and reviews the literature. He insists
upon the recognition of a contraction ring as a condition distinct from,
and very different from, a retraction ring or ring of Bandl. Its causes
are premature rupture of membranes, intra-uterine manipulation,
increased irritability of the uterus, malpresentations, uterine inertia,
and parity. The prognosis is bad ; in his series of cases not treated
by laparotomy, the maternal mortality was 38 per cent and the foetal
63 per cent, while in cases treated by laparotomy the maternal mortality
is 31-5 per cent and the foetal 42 per cent. The three varieties of treat-
ment which are most useful are Continuous Weight Traction, Embryotomy,
and Caesarean Section. Of these he considers that Caesarean section
gives the best results.

References. — '^Dublin Med. Jour. 1913, ii, 180 ; ^Jouv. Amer. Med. Assoc.
1912, ii, 772; ^Presse MSd. I9i3> 663; ^Brit. Med. Jour. I9i3> i, 1105:
^Miinch. med. Woch. 1913, 815 ; ^Birm. Med. Pev. 1913. 173 ; "^Liverp. Med.-
CJiir, Jour. 1913, 167 ; ^Lancet, 1913, i, 604.

LABYRINTHITIS. {See also Vertigo.) Geo. L. Richards, M.D.

Henninger,^ from a review of the literature of acute labyrinthitis,
finds it to be either serous or purulent, and due to an invasion of the
labyrinth by toxins or pathogenic germs. It may be dilTuse or circum-
scribed, and arises as a complication in acute or chronic suppuration
of the middle-ear and mastoid, and also during the course of severe
infections, as diphtheria and scarlatina. In serous labyrinthitis the
onset may be either sudden or gradual, the temperature normal or
slightly elevated ; the pulse is usually rapid. Tinnitus, dizziness,
nausea, and disturbance of equilibrium are often complained of. The
hearing is reduced, but the vestibular apparatus responds to stimulation.
Spontaneous nystagmus is present, and is directed toward the diseased
side. These conditions indicate the early stages with gradual onset.
Cases of sudden onset present conditions difficult to differentiate from
the purulent type. Purulent labyrinthitis produces nausea and
vomiting, fever, headache, tinnitus (early); deafness later, nystagmus,

LABYRINTHITIS

326

MEDICAL ANNUAL

loss of labyrinthine irritability, and vertigo. The onset is sudden, with
a distinct rise in temperature, often accompanied by facial paralysis.
At first the nystagmus is to the diseased side, but later in the progress
of the disease the end organs of the vestibular nerve lose their function
and the nystagmus is to the sound side. This is often known as
increased irritability of the sound labyrinth. The vertigo and disturb-
ance of equilibrium continue for several days, and the patient, unable
to assume the erect position, lies on the side towards Avhich the
nystagmus is directed. All efforts to stimulate the vestibular apparatus
are futile, and by applying the Neumann noise apparatus ” to the
sound ear, the diseased ear is found incapable of detecting the most
penetrating sound. Complications arising from purulent labyrinthitis
may be meningitis, cerebral or cerebellar abscess ; the latter is the most
frequent. Acute purulent labyrinthitis must be differentiated from
cerebellar abscess, as nystagmus plays an important factor in both
conditions. Nystagmus towards the affected side may be due to an
early circumscribed labyrinthitis or a cerebellar abscess. A cerebellar
abscess cannot be excluded prior to an operation on the labyrinth.
After a conjoint radical mastoid and labyrinth operation, if the rotatory
nystagmus is directed towards the diseased side, a diagnosis of cerebellar
abscess can be made. Serous labyrinthitis calls for a mastoid operation,
simple or radical, after wliich the patient is carefully observed. Cases
with labyrinthine complications following acute mastoiditis or an
acute exacerbation of a chronic process, are put to bed for absolute
rest, after removal of the primary foci. Circumscribed labyrinthitis
is treated expectantly.

Dench® believes that in the future, labyrinth exploration will be
performed in certain cases of impairment of hearing progressive in
type and involving the labyrinth. He describes an ideal operation
as performed upon the cadaver for non-suppurative labyrinthine
lesions. This operation can be performed through the ordinary
mastoid operative field without a preliminary radical operation,
provided the zygomatic cells have been included. In order to obtain
a perfect view of the promontory, and enable the operator to remove
the bony wall of the first, and a portion of the second turns of the
cochlea, by taking down the ridge of bone separating the oval and
round windows, it is necessary to perform a complete radical operation ;
but such interference with the cochlea is not necessary in cases suffering
from vertigo.

Shambaugh^ operates upon the labyrinth in cases of labyrinth
suppuration when clinical symptoms exist which suggest an early intra-
cranial complication, such as altered cerebrospinal fluid, severe
unilateral headache, etc. ; where the labyrinth empyema develops as
a part of a violent acute panotitis ; where the indications for a mastoid
operation exist ; where it develops as a sequel to chronic purulent
otitis media, with clear indications for a radical mastoid operation ;
where the labyrinth suppuration is complicated b}' erosion of the
labyrinth capsule, by fistula fonnation into the labyrinth, by facial

NEW TREATMENT 327 LACRYMAL APPARATUS

paralysis or by sequestration, of a part or the whole of the labyrinth
capsule.

Lewy^ finds degeneration of the nerve of hearing more apt to occur
in men, in those who work in a continuous noise, and past middle
age. In young people it may follow the infectious diseases, meningitis,
mumps, or hereditary syphilis, without being preceded by suppurative
lesions. The patient comes to the otologist too late. Loss of hearing
is usually severe, and is unequal in both ears, with a marked loss of
the upper tone limit. Quinine, alcohol, and tobacco play an important
part in its etiology.

References. — '^Laryngoscope, 1913, July; -/M. Aug. ; '^Ann. Otol, igi^,
June; ^Larynigoscope, 1913, Mar.

LACRYMAIi APPARATUS, DISEASES OP THE.

A, Hugh Thompson t M.D.

As an alternative to excision of the sac in obstinate cases of obstruc-
tion of the nasal duct, operations have been devised to establish a new
channel by means of which the lacrymal sac may be drained directly
into the nose. The best known of these operations is that of Toti, thus
described by Harrison Butler^: ''Toti exposes the sac, turns it back,
and cuts a window in its inner wall. He now chisels out a piece of the
adjacent bony wall of the nose and exposes the nasal mucosa. The
nose is packed with gauze after removal of the inferior turbinate bone,
if necessary, and, in some cases, of some of the ethmoidal cells. A
window is cut in the nasal mucosa the same size as that in the lacrymal
sac, and the edges of the two fenestrse are united by sutures. Toti
claims that after this operation the natural drainage of the conjunctival
sac is restored. Not only can fluid be freely syringed into the nose,
but fluorescein instilled into the conjunctival sac appears in the nose.”

West’s^ operation is very similar, but he lays stress on the preserva-
tion of the inferior turbinated bone. One would think this would make
the operation an extremely difficult one ; but West, who has had at his
disposal a large number of lacrymal cases from the clinic of Professor
Silex, in Berlin, claims to have had very good x'esiilts in qo per cent, of
them. Neither this nor Toti’s operation, however, is likely to find much
favour with the majority of ophthalmic surgeons, for three reasons:
the technique is difficult except to the practised rhinologist ; there is a
risk of septic infection starting from the nose and travelling by the new
route to the eye; and extirpation of the lacrymal sac, if efficiently per-
lormed, is quite a satisfactory operation in the great majoitty of cases.
A consideration to the contrary, however, is pointed out by Wray —
namely the possibility that it may predispose to senile ectropion, a
condition which partly depends on preservation of the tear passages in
their natural state. Whether this is so or not will hardly be known
until there are a sufficient number of old people who have had their sacs
removed in earlier life. Wray himself, recognizing the objections to
the nasal methods of operating, adopts a modified form of the old
treatment by styles inserted into the nasal diict.»

LACRYMAL APPARATUS

32S

MKDTCAL ANNUAL

In some cases it is impossible to cure dacryocystitis without dealing
w’ith the accompanying caries or inflammation of the ethmoid bone,
and Rhese^ insists on the importance of co-operation between nasal
and ophthalmic specialists in these cases. The only satisfactory
method of diagnosing ethmoidal disease, he says, is by means of
A'-rays. In cases where the diseased ethmoid can be dealt wdth
hy operative measures, the prognosis of the lacrymal disease becomes
extremely good.

References. — Med. Jour. 1913, ii, 1144; ^BerL kiln. Woch. 1913,
926 ; ^Med. Press a>id Circ. 1913, ii, 535 ; ^Deut. med. Woch. 1912, 1646.

LARYNX. TF. G. Porter, M.B., F.R.C.S.

Radiography. — Rethi,^ dissatisfied with lateral pictures of the larynx,
and finding it impossible to take an antero-posterior picture by the
ordinary method, owing to the thickness of the spinal column, had the
idea to overcome this difiiculty by placing a film directly behind the
larynx in the h3rpopha]:ymx, and making the exposure from before
backwards. He w’as at once successful. It is very important that
the films should be cut to the right size and properly packed. It must
be larger above to fit the h^^popharynx, and narrower below to pass into
the oesophagus, and the corners must be carefully rounded. It is laid
on a piece of cardboard which is cut to the same size and WTapped in
tinfoil. The cardboard and film are then wrapped, first in black light-
proof paper and then in wax-paper, so that it is both light- and water-
tight. The pharynx and hypophar5mx must be carefully anaesthetized.
The photograph is taken with the patient lying down and with the head
slightly bent baclavards, but as the film is introduced it must be slightly
bent forwards. The film in its wrappings is made slippery with liquid
paraffin, introduced with the second and third fingers of the left hand,
and pushed home with the same fingers of the right hand. The patient
must now breathe quietly, and the exposure is made. The film is then
removed with a pair of forceps: The length of exposure naturally
depends on the apparatus ; short exposures are less disagreeable to
the patient. In the skiagram the body of the hyoid bone is clearly
seen above [Plate XXV). Occasionally, the epiglottis can be seen below
as a triangular shadow whose rounded upper border extends above the
hyoid bone. The body of the thyi'oid cartilage appears as a shadow.
The false cords, the true cords, and the sinus are clearly distinguish-
able. Anatomical alterations, e.g., recurrent paralysis, are readily
recognized, while stenoses and the extent of malignant disease can
also be determined.

Suspension Laryngoscopy. — Killian, ^ to whom laryngology owes
so much, has greatly added to his services by devising an entirely new
method of directly inspecting the larynx, which he has termed suspension
laryngoscopy. By it an extremely good and complete view is obtained
of the pharynx, the larynx, and the hypopharynx [Plate XXVI) . It con-
sists in suspending the head, which is allowed to hang over the table,
by the lower jaw, by means of a tongue spatula, which is hooked on to

PLATE XXV.

RADIOGRAPHY OF THE LARYNX

Skiagram of lar\'n.\ by Kethi's mcthoil.

Jllnsifatioii h'tit by Jub/fo/'s o/" /irits, Ji'tr Liirym^.

.]/ E2'>/C.-l L AyXLWJ., ig/^

PLATE XXVI.

KILLIAN’S SUSPENSION LARYNGOSC;OPY

The head, hanging over the table, is suspended by the lo^\er jaw by means of a
tongue spatula hooked on to a gallows.

ME/hT.lL AXXL'AL,

NEW TREATMENT

329

LARYNX

a gallows consisting of an iron bar bent nearly at a right angle, which
can be moved easily by cranks upwards, down-wards, forwards, and
bacliw^ards. The horizontal part of the bar is hollowed out in several
places in order to receive the hook spatula. This consists of three
parts : the handle, the tongue spatula, and the mouth gag. The exam-
ination may be carried out under local anaesthesia in a tolerant patient,
but if chloroform is given it should be preceded by an injection of
morphine and scopolamine. The gallows is fixed to the right of the
table, and the surgeon is seated opposite the end of the table.
The patient is placed with his head projecting over the end of the table
and hanging slightly back. To suspend the patient, the spatula is
hooked on to the gallows, which is then adjusted until its mouthpiece
can enter the mouth. Until the final adjus-tment of the spatula is made,
the head is supported ; after that it is allowed to hang free. Once the
instrument is in place, the surgeon has both hands free for any operative
interference, and there is no doubt that the larynx and hypopharynx
are made much more accessible by this than by any other method of
examination. From Killian's own experience, and -that of others who
have practised the method, it may safely be predicted that it has a
future. FreudenthaP has found it of great practical value, especially
in the operative treatment of tuberculosis and tumours of the larynx.
Davies^ has also found it of use in a number of cases, including one
in which he removed a pin from the lo-wer pharynx in an infant aged
II months.

The Epiglottic Suime, — Horsford® has modified his instrument for
passing a suture through the epiglottis to facilitate intralaryngeal

Fi^. 3Q. — ^Ilorsford’s epiglottic suture fotceps.

inspection and indirect operative procedure [Fig. 39). This instrument
is a modification of Kurz's forceps used for the passage of deep sutures
in pelvic surgery. Before its employment, cocaine is applied to both
surfaces of the epiglottis, and the needle is threaded with silk and
placed in the proximal blade. With the aid of a laryngeal mirror, the
forceps are introduced into the throat until the upper border of the
epiglottis is seen to pass between the point of the needle and the distal
blade ; the blades are firmly closed and then opened, and the instrument
withdrawn ; it will then be found that the suture has passed through
the epiglottis. The ends are gripped by a pair of forceps and allowed
to hang below the jaw. A third hand is not required to hold them.

Cancer. — ^hfcKenzie, ® in a case of Laryngectomy for laryngeal cancer
in which a tracheotomy had previously been carried out, modified the
usual technique of dividing the trachea and bringing the cut end

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through a slit in the skin just above the episternal notch. Instead of
this, he closed the upper opening in the stump of the trachea and
retained the tracheotomy tube. The closure of the trachea prevented
discharge finding its way into the lungs. The result was eminently
satisfactory.

Crile^ has performed 27 laryngectomies for cancer, with 2 operative
fatalities, or a mortality of 7 per cent. The special dangers of the
operation are pneumonia, local infection, mediastinal abscess, vagitis,
and reflex inhibition of the heart and respiration through mechanical
stimulation of the superior laryngeal nerves. To avoid mediastinitis,
a preliminary low tracheotomy is performed, and at the same time the
deep planes of the base of the neck are opened and packed with iodo-
form gauze, a strong protective barrier of granulations being thus
formed. The general anaesthetic of choice is nitrous oxide, but ether
may be given. A piece of rubber tubing slightly larger than the trachea
is substituted for the tracheotomy tube through which the anaesthetic
is administered ; the site of the skin incision is infiltrated with novocain,
and the larynx completely freed. The trachea or cricoid is divided
at a level free from the disease, novocain being again infiltrated at this
part. The larynx is raised and separated from the oesophagus. The
upper end of the larynx is then cut free. The opening in the pharynx
is sutured and the rest of the wound left open. With this wide open-
ing, secretions may be prevented from entering the trachea, which is
left lying in its natural bed.

Della Vedova and Castellani® treated two cases of carcinoma of the
larynx by. Early Thyrotomy. In the first, the operation had been
performed four years before publication. The patient at that time
was 48 years old. The tumour was situated at the middle of the left
vocal cord. The voice was fairly good, although the whole of the left
vocal cord was removed. The second case was reported eleven months
after the operation. The patient at that time was aged 60 ; the whole
of the right cord was involved in a red swelling, which had an irregular
surface. In this case also the functional result w^as satisfactory. In
neither case was there a trace of recurrence. The authors mention in
their paper that they had operated on 12 cases by thyrotomy for
cancer of the lar^mx between the years 1907-1911, with 7 cures ;
there wei*e 2 deaths through post-operative inflammation of the lungs,
while 3 of the cases which were dismissed as cured had not returned to
report. In 5 additional cases they had operated by the intralaryngeal
method ; in none had there been a recurrence ; one of these was
operated upon in 1907.

Tuberculosis , — Sir St. Clair Thomson® states that tuberculosis affects
the larynx more frequently than any other disease. In the later stages
of pulmonary tuberculosis, the disease is discovered in the larynx in
72 per cent of cases. The principles of Sanatorium Treatment must
be insisted upon, tobacco and alcohol should be abandoned, and, in
early cases, strict silence should be enforced. When there is marked
dyspnoea, a Median Tracheotomy is carried out under local anaesthesia.

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331

leishmaniasis

In the author’s experience, treatment with tuberculin had no efect in
the majority of cases. Relief to dysphagia may be obtained by a
laryngeal insufiftation of 3 to 5 gr. of Ansesthesin, or by the injection of
Alcohol into the superior laryngeal nerve.

Chalier and Sonnet’® advocate Division of the Superior Laryngeal
Nerve in cases where these measures have failed to give relief. It is
a simple operation, and can be carried out under a local anaesthetic.
A horizontal incision is made, 4 cm. in length, between the hyoid
and thyroid cartilages, extending forwards from the anterior border
of the sternomastoid. The nerve is looked for on the thyro-hyoid
membrane, and is divided there, care being taken to avoid injury to
the external branch.

Stenosis following Diphtheyia, — Richardson^^ believes that the follow-
ing are causes of stenosis following diphtheria : (1) Prolonged intuba-
tion, laryngotomy, or high ti'acheotomy ; (2) The severity of the attack
and the presence of a secondary infection ; (3) Injury to the larynx
during intubation or extubation. To prevent the development of
stenosis he advises that intubation should not be prolonged much
beyond a month. Tracheotomy should then be resorted to, if
necessary, and should be done as low as possible. If stenosis develops,
intermittent dilatation should be carried out under direct vision until
the larynx reaches about normal size.

Paralysis. — Dundas Grant’® reports two very unusual cases of
recurrent paralysis of the left vocal cord apparently due to alcohol
as a toxic agent, in which recovery ensued after abstention from
alcohol. He points out that toxic paralyses are usually bilateral.
Dorendor’® discusses the effect of auricular enlargement as a cause of
recurrent paralysis of the left vocal cord. He believes that the
anatomical possibility of this condition has not been sufficiently proved.
In four patients with left recurrent paralysis which he observed in cases
of mitral stenosis, he convinced himself that the paralysis was not clue
to the enlargement of the auricle, but to an extension of in Ham mat ion
from the pericardium (which was px'esent in his cases) to the ]>oslerior
mediastinum, in which the vagus and recurrent laryngeal nerves lie.
He thinks that in several of the previously juiblished c ases uu‘<liastinitis
was probably the real cause of the paralysis.

References. — '^Zeits. f . Laryng. 191 s. 27; -Anh. f , Luryug. injj, 277:
'^Med. Rec. 1913, i, 32S ; ^Bvit, Med. Jour. 1913. i, 115; '‘Ibid. ;
^Lancet, 1913, ii, 2S7 ; '^Auu. Surg. 1913/ ii, 164; '*^Zeiis. f. Luryng. yi, :
^Pract, 1913, i. 243; ^^Presse Med. 1912. 931 ; ^^Bost. Med. and Surg, Jour.
1913, i, 749 : ^’^Lancef, 1913, ii, io| ; ^''^Bevl. Min. Woch. 1913. i, 912.

LEISHMANIASIS* {See also Anaemia in Children.)

Leonard Rogers, M.D., F.R.C.P.

A discussion on this subject at the British Medical Association’
w'as opened by Patton, who summarized the investigations he had
carried out during the previous seven years on the role of insects in
‘ carrying the infection. He agrees wdth Rogers in considering the
flagellate stage as an insect herpetomonas, and the only insect in which

LEISHMANiASIS

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MEDICAL ANNUAL

Jie has found it to develop is the bed-bug. Recently, he has found that
when the flagellate stage has developed in a bed-bug, it is killed by a
second feed of blood. He has failed to infect dogs or monkeys, and
until a susceptible animal is found, the final step in the transmission
of the disease cannot be accomplished. At the safne meeting, Fantham
described some flagellates naturally met with in insects' alimentary
canals, which must be borne in mind in studying the transmission
of protozoal diseases by their means.

Row^ has succeeded in producing local lesions in monkeys by the
injection of both fresh human parasites and cultures of the same. The
incubation periods were nine weeks and three months respectively.
Even after ten months the condition remained localized, and the general
health of the monkey was not affected. One nodule atrophied and
became absorbed. One nodule was excised two weeks after its appear-
ance, and showed the parasites in the tissues. Fi*om this, two mice
were injected intraperitoneally and developed general infection. A
monkey infected intraperitoneally at the same time remained appar-
ently well, but four and a half months later its liver on aspiration
showed typical kala-azar parasites, proving a general infection. A
second passage into mice failed.

Castellani^ records a case of intractable ulcers of the pharynx in
which he found Leishman-Donovan bodies. Previous anti-syphilitic
treatment had failed. There were no cutaneous lesions, but he had
suffered fi'om fever occasionally. The throat condition had persisted
for nine years.

H. Seidelin'^ describes a form of Leishmania tropica he met with in
Yucatan in Mexico, 'which is characterized by the ear being the seat
of the infection. He found the parasites in four out of six cases, the
two negative ones haying been examined only once. Darling and
Connor had described a similar case at Panama.

Umberto Gabbi^ maintains the identity of infantile kala-azar of
North Africa and the adult form of the disease ; in confirmation
he points to Marshall’s successful infection of dogs with parasites
of the adult disease, and also quotes Nicolle’s opinion in favour of
his view.

R. A. P. Hill® has studied kala-azar in North China, and has noted
that the red corpuscles in this disease' alone do not dissolve, but- run
into lumps, not easily broken up by shaking in the special leucocyte
diluent he uses. This is composed of : [a] Wright’s modification of
Leishman’s stain, saturated and filtered, 2 parts ; pure methyl alcohol,
I part ; ( 6 ) o*i per cent solution of pure sodium chloride in distilled
water. Add i part of [a) to 2 parts of ( 6 ), shake well, and use within
half an hour. He suggests that the peculiar behaviour of red corpuscles
in this solution may be diagnostic of kala-azar, as he found it in eight
consecutive cases, but never in other forms of enlarged spleen, such as
malarial.

Treatment. — O. v. Petersen ^ reports on the treatment of Oriental
sore with Salvarsan, based on 120 cases, and concludes that it is a

LEPROSY

NEW TREATMENT 333

Specific in doses of 0*4 to o *6 gram intravenously, several injections
being often required.

References. — Med. Jour. igi2, ii, 1194; ^Ibid. 1196; Jour. Trop.
Med. and Hyg. 1912, 327 ; Jhid. 1913, i ; ^Ihid. 49 ; ^Ann. Trop. Med. and
Hyg. 1912, 295; ^Jour. Trop. Med. 1913, 198; ^Lancet, 1913, ii, 392; ’^Mufich.
med. Woch. 1912, 2491.

LEPROSY. Leonard Rogers, M.D., F.R.C.P.

Bacteriology. — The controversy between those who have culti-
vated different organisms from leprosy cases still continues. At the
British Medical Association meeting of 1912, Duval and Bayon^ read
papers on their respective organisms, based on investigations recorded
in the last Medical Annual, and in the discussion G. Dean stated that
much more work was required on the subject before any safe conclusions
could be arrived at. At the same meeting M. E. Marchoux dealt with
rat leprOS}^, the infection of which is conveyed from one animal to
another by bites. Bayon, in a further paper, ^ gives a good summary
of his position, and records local and febrile reactions in lepers by intra-
dermal injections of an extract of his organism made on similar lines
to Koch’s tuberculin, while healthy controls did not react. If these
results are confirmed by further experience, they will be of great value
in effecting an early diagnosis of the disease, w’hile they will go far
tow^ards establishing his organism as the cause of leprosy. He has
been able to produce leprosy -like lesions in rats with the bacillus first
cultivated by Kedrowsky and later by himself, but obtained negative
results with Rost’s and Duval’s bacilli.

S. P. Impey® records an interesting account of his experience of the
symptoms and diagnosis of leprosy at Robben Island. He thinks the
dangers of contagion are very slight in the nodular form, and absent in
the anaesthetic variety. Mixed forms are uncommon, and in them both
varieties of lesion exist from the first. The tuberculous form should
only be diagnosed by finding bacilli in the serum of the lesions, or in
the nasal discharge, where they are often present early in the febrile
stage. In warm countries the nodules are commonly limited to exposed
parts, especially the face, wrists, and ankles, and are rare on the trunk.
In the anaesthetic form he thinks the bacilli are only found during the
first four years, the later lesions being due to the damage already done
to the nerve trunks. As the bacilli cannot be found, the diagnosis is
often difficult at first, but the limitation of the affection to the nerve
trunks not extending much above the elbows and knees is significant.
The anaesthetic patches do not contain the bacilli. Ulceration is caused
by injuries to the anaesthetic parts, such as b}^ burns, etc., which cause
no pain.

H. Bayon^ publishes a further full review of the literature of leprosy,
including his own valuable work, illustrated by excellent coloured
plates. The bacteriology and animal experiments are dealt with, and
the evidence in favour of the contagiousness of the disease set out.

Treatment. — Creighton Wellman® records a trial of Salvarsan
injections in the treatment of leprosy. The presence and condition

LEPROSY

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MEDICAL ANNUAL

of the leprosy bacillus \vere ascertained before and after the doses.
Out of 6 cases, i died from accidental burns before the observations
were completed. Clinical improvement occurred in 4 of the 5
remaining, but in only 2 of them did the organisms disappear from
the tissues, although in 4 partial or complete resolution of the
nodules examined microscopically was found. He is doubtful if
salvarsan gives better results than other preparations of arsenic, which
have long been used with benefit in the treatment of leprosy.

T. C. Hutherfoord*’ has treated 20, cases of leprosy in India with
weekly injections of “ Leprolin ” for from 100 to 153 days. Full
tabulated notes were taken before and after the treatment, and the
changes in each symptom noted. An analysis of these data showed
that in only 3 cases did the number of symptoms which improved
exceed those in which deterioration took place, while retrogression
was in excess of improvement in 14, probably as a result of the natural
progress of the disease, although in one it was so marked that it seemed
most likely to have been caused by the treatment.

T. S. Davies'^ reports one case in which injections of an extract made
from a culture of Bayon’s produced remarkable improvement. ,

T. L. Sandes^ deals with the Surgery of leprosy, by means of which
so much relief can be afforded. Anaesthetics are often unnecessary,
and owing to heart atrophy, ether or lumbar anaesthesia is preferable
to chloroform. Ulcers require rest and antiseptic treatment ; if exten-
sive, scraping and skin-grafting may be useful. In the case of necrosis
of small bones, such as phalanges, it is best to remove them completely.
Nerve anastomosis may sometimes be indicated for paralysis. Amputa-
tion by circular incision is occasionally necessary for extensive ulcera-
tion. E. S. Goodhue® also writes on the surgical cure of leprosy, and
thinks that if the primary lesion can be detected early it might be
excised with success,

A. Heymans^^ and D. J. Wood wTite on the eye complications of
leprosy, the former especially dealing with lagophthalmus,” and a
method of operating to remedy the affection and save the exposed eye
from injury.

A dministrative Measures. — Bayon^^ has also dealt at length with this
aspect of the question in a report to the Cape Government on the
Robben Island Asylum, and advises universal segregation under more
comfortable conditions in order to stamp out the disease for good.

References. — Med. Jour, 1912, ii, 1189; ^S. Afr, Med. Jour.;
® 5 . Afr. Med. Rec. 1913, 239 ; *Ibid. 201 ; ^N.Y. Med. Jour. 1912, ii, 996 ;
^Ind. Med. Gaz. 1913, 6r ; ’ 5 . AJr. Med. Rec. 247 ; ^Ihid. 230 ; ^N.Y. Med.
Jour. 1913, ii, 266 ; Afr. Med. Rec. 1913, 246; ^^Ibid. 187.

liEUKiEMIA. {See also Leukemic Eruptions of the Skin.)

Herbert French, M.D., F.R.C.P.

Etiology. — A^arious attempts have been made from time to time
to produce leukaemia experiinentalh’’ in animals by the use of blood or
organ-extracts derived from human cases of the disease. Hitherto
these attempts have proved abortive, but if some recent work done by

NEW TREATMENT

335

UUK/EMfA

Wiczkowski^ is confirmed, considerable light will be thrown upon the
pathology of this remarkable disease. He injected intravenously into
fowls (i) blood, (2) emulsion of freshly excised lymphatic glands,
and {3) pleuritic exudate, all derived from the same patient suffering
from leukaemia. Those fowls that received blood or gland-emulsion
remained perfectly well ; but those into which leukaemic pleural
exudate was inoculated fell seriously ill, with symptoms closely
analogous to those of the original leukaemia. The mucous membranes
became blanched, the feet cedematous, the general condition went from
bad to worse. The blood-picture, originally normal, passed on tp one
of great lymphocytosis. After death, the spleen was found to be
enlarged, the bone-marrow red, the liver swollen, with diffuse white
punctate deposits of tymphocytic infiltration. Blood taken from fowls
that gave this reaction to human pleural exudate injected into ten
other healthy fowls, produced a similar positive result ; and Wiczkowski
is now engaged in further experimental work, using the blood of these
fowls in an attempt to produce leukaemia in quadrupeds.

Diagnosis. — Another step towards linking together the lymphatic
and the splenomedullary leukaemias, the interrelationship between
which seems so probable, is taken by Heschad.^ He claims to have
discovered an entirely new kind of leukaemia which he styles " spleno-
cytic ; ” his splenocytes ” do not appear to be an entirely new sort
of cell, .however, but rather transitional between large lymphocytes
on the one hand and myelocytes upon the other. That the blood of
a case of splenomedullary leukaemia may sometimes change to a
lymphaemic type in the last stages, has been known for some time ;
Reschad now shows us that a case may have an intermediate blood-
picture throughout its course, not in the sense that both lymphocytes
and myelocytes are abundant at the same time, but in the sense that
the predominant cells present are neither large lymphocytes nor
myelocytes, but something midway between the two. He calls these
intermediate white corpuscles “ Uebergangsformen," or “splenocytes.”

Dunn,® on the other hand, holds that it is impossible to tell from
ordinarily stained films, whether the leucocytes in leuksemic blood arc
really large lymphocytes, and he states that many cells so termed by
observers in the past are really immature myelocytes — myeloblasts ;
and that, in order to distinguish myeloblasts from lymphocytes, it is
necessary to stain the blood-films by the indo -phenol-oxydase process.
This consists in fixing the films by immersion in i per cent osmic acid
for five seconds, washing thoroughly in running water for five minutes,
and then immersing in a mixture of equal parts of : —

Di-methyl-paraphenylene-diamine, per cent aqueous solution

Alpha-naphthol - - - , - saturated aqueous solution

for periods varying up to half an hour. The films are then washed
for a few minutes in running water and mounted on slides in a
mixture of equal parts of commercial water-glass and tap- water.
Normal blood-films treated in this way show a deep-blue staining of

LEUK/EMIA

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MEDICAL ANNUAL

the polymorphonuclear leucocytes, owing to the formation of indo-
phenol in their protoplasm in consequence of the oxydizing ferment or
oxydase present in them. Lymphocytes contain little or no oxydase ;
myelocytes and most myeloblasts contain it, and therefore stain blue
by the above process, and Dunn’s researches show that many cases of
supposed lymphatic leukaemia are really examples of acute myeloid
leukaemia, the prevailing cells being myeloblasts or precursors of
myelocytes, and not large lymphocytes as hitherto supposed.

The diagnosis of leukaemia is generally based upon the existence of
a considerable or extreme degree of leucocyte increase in the blood ;
but various circumstances may cause the blood to show no such increase,
although the disease is undoubtedly leukasmia ; this is often the case,
for instance, after treatment by repeated local application of ;ir-rays to
the splenic region ; or again, after the administration of benzol either
by the mouth or by injection. It is not surprising, therefore, that the
disease sometimes presents itself clinically without leucocytosis —
even when there has been no treatment — aleucocythtsmic leukcBwiia,
Three cases of this kind are reported by Waterhouse^ ; two were adults,
one a child. The symptoms common to the three cases were profound
anasmia, hcemorrhages (especially epistaxis), irregular pyrexia, enlarged
glands, the cervical being specially affected, and slight enlargement of
the spleen. The blood in all cases was pale and watery, but clotted
rapidly.. The red blood-cells numbered about a million and a half,
the haemoglobin being diminished but little more in proportion, so that
the colour-index was only just below normal. As regards the leuco-
cytes, the count varied between 3,000 and 11,300, except that just
before death the blood became crowded with lymphocytes. Basophils
(with one or two doubtful exceptions) and eosinophils were absent in
all films examined. The polymorphonuclear cells were diminished in
number in every instance, and generally very markedly. The lympho-
cytes were generally about normal in number, but were sometimes
grehtly increased. There was always a relative increase. Post-
mortem examinations in all these cases disclosed lesions typical of
lymphatic leukaemia.

A fresh case of nodular leukaemia, also without leucocytosis, is
recorded by Reid, Calwell, and Thomson.® The diagnosis was afforded
partly by the clinical symptoms, but mainly by the positive oxydase
reaction of the leucocytes {vide supra).

Chloroma. — Bierring® reports two new cases, and summarizes the
literature. Each patient presents almost the same symptoms, and it
is not difficult to diagnose the disease. It is, however, not a distinct
pathological entity, but rather a peculiar variety of leukaemia. The
painful exophthalmos, with gradual developing visual disturbance,
earache, and deafness, frequently first directs the patient to the specialist,
and that probably accounts for the fact that the earlier cases reported
■were first seen by the oculist or the aurist. In rare instances, the
internist is consulted by reason of the progressive anaemia, general
and purpuric or haemorrhagic manifestations. When once

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LEUK/EMtA

the disease is manifest, it takes a rapid course, being more marked in
younger patients. The average duration is from three to four months,
only quite exceptional cases surviving for over a year.

Two distinct forms are recognized, the lymphatic and the myeloid,
the former being much the more frequent. There may be no absolute
ieucocytosis, but more often there is some ; and the white cells may
number from 300,000 to 1,880,000 per c.mm. In both forms the
haemoglobin content is usually greatly diminished, the red cells
becoming also variably reduced in number from 3,000,000 down to
1,000,000, and even less, per c.mm. The colour-index is usually minus.
The morphology of the red cells is such as characterizes the different
severe anaemias, and changes in form and size, poikilocytosis, poly-
chromasia, and occasional basophilic degeneration, have been observed.
Nucleated red cells are frequently noted. The erythroblasts are seen
to be most numerous in the younger patients. The anaemia usually
becomes more pronounced in the later stages of the illness, and is often
augmented by external influences, such as excessive haemorrhage
through epistaxis, haematemesis, haematuria, etc.

The spread of tumours in the cranial and facial bones explains most
of the characteristic symptoms. Tumours in the orbit produce a
marked prominence and crowding of the bulb, giving rise to the
symptoms of exophthalmos, and, as the lids are unable to cover the
bulb, the sight soon becomes disturbed and finally is destroyed. As
the tumour spreads on the facial bones and the temporal region, the
deformity produced in the skull leads to a peculiar frog-like
aspect, which permits of an easy diagnosis at the first glance. By the
predilection of the tumours for the periosteum and dura mater of the
cranial bones, the involvement by^pressure of the cranial nerves is easily
explained. It is peculiar that only three nerves are usually involved :
the optic, by reason of orbital pressure ; the facial ; and the auditory,
on account of the involvement of the temporal bone.

Treatment. — Koranyi^ records 8 cases of leukaemia treated with
benzol. In i, neither A^-rays, thorium-^r, nor benzol did any good ;
in I the benzol could not be taken ; in the remaining 6 it was most
beneficial ; the leucocyte counts fell from hundreds of thousands to
about 12,000 ; the spleen shrank ; enlarged glands disappeared ;
the erythrocytes rose steadily to nearly normal ; and the patients
averaged an increase of weight by 10 kilos each. He agrees that it
is too early to say what the permanent effects are, but he is convinced
of the benefits obtained temporarily.

Klein® holds that up to the present he has seen the best results
obtained in the treatment of leukaemia from the use of the X-rays,
though even with these the effects are but partial and temporary ;
some cases, however, do not seem to benefit at all, and in 22 he
tried the Benzol treatment, either as well as, or instead of, the ;i;-rays.
Three of these were cases of acute, x subacute, 14 chronic myeloid
leukaemia, 4 lymphatic leukaemia. Ten had been under observation
too short a time to warrant conclusions, but he reports the results

LEUK/EWIIA ^38 MEDICAL ANNUAL

in the remaining 12 in detail — 8 chronic and i subacute myeloid,
and 3 l^TOphatic. He gave from 2 to 5 grams of benzol daily,
mixed with equal parts of olive oil, in gelatin capsules, usually by
the mouth, but occasionally by intravenous injection. His general
conclusion is that benzol given by the mouth is of great value in the
treatment of certain cases of leukaemia ; that it is uncertain in its
action, however ; that it may cause so much gastro-intestinal irritation
that it has to be discontinued, although in others it does not upset the
stomach at all ; that it seems to exert a specific stimulating action on
the blood-forming centres ; that, contrary to expectation, it seldom
leads to renal irritation ; and that it acts particular!}?- well in cases that
are having ;t;-ray treatment of the spleen at the same time.

Stern® reports one case of leukaemia treated by him with benzol, and
speaks highly of its value. The leucocytes fell in three months from
264,000 to 15,200 per c.mm., the myelocytes disappearing almost
completely. The spleen returned to normal size, the patient felt
strong and well, and had gained 2 kilos in weight.

Wachtel,^® from personal experience, says that although benzol may
be very beneficial in some cases of leukaemia, and is much more applic-
able in private practice than thorium or Ar-rays, it has to be used with
great caution, and the patient closely watched. Of two recent cases of
his, one took the benzol quite well for six weeks continuously, with no
other ill effect than unpleasant eructations from the stomach ; the
leucocytes fell from 139,000 to 13,000 per c.mm. in five weeks ,* in the
other case, however, albuminuria was produced almost at once, and
the drug had to be stopped in three days.

Billings^ ^ records similar good results in five cases treated with benzol
given in gelatin capsules filled at the time of administration. One
patient took the drug in an emulsion, made up by the hospital druggist,
of which two teaspoonfuls equalled 15 min. of benzol. The drug
was given soon after meals and at bedtime. The dose at first was
7 min., which was soon increased to 15 min. All patients complained
of eructation of gas, tasting and smelling of benzol. Burning in the
stomach was a common symptom. Dizziness was a complaint of two
patients. One patient left the hospital, and misunderstanding the
order for the medicine, increased the daily dosage to 160 min. Within
a few days he su^ered from a severe toxic erythema and pruritus of the
skin of the whole trunk and extremities. The drug was discontinued,
and within one week the erythema disappeared. On resuming the
benzol in the dose of 60 min. per day there was no further trouble. As
a rule, the appetite was not disturbed, with one exception, and in this
patient the general nutrition remained good. Of the other four, all
gained in weight. No other medicine was given except the necessary
laxative, or occasionally the mixture of rhubarb and soda as a stomachic.
Generally the patients were kept at rest. The benzol used w^as that
obtained by the hospital druggist, and no analysis was made for the
presence of nitrobenzol onanilin. The urine of the patients was not
examined for nitrobenzol or anilin. The urine did not contain a

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LEUKAEMIA

perceptibie increase of uric acid during the rapid leucocytic destruc-
tion, nor was there general disturbance coincident with the destruction
of the enormous number of leucocytes in so short a period.

The chief notable results of the benzol medication were a marked
rise in the leucocytic count for a few days in two patients (in three
patients this was not obser\’ed) ; a rapid fall in the number of leuco-
cytes ; a correspondingly rapid diminution in the size of the spleen,
much more rapid than ■with A'-ray exposures alone ; an improvement
of the red-cell count and haemoglobin in all of the myelogenous types ;
a rapid disappearance of the small though multiple lymph-nodes in the
patient with lymphoid leukaemia ; and marked general improvem ent
in all. The treatment was applied at the same time, in all but

one of the cases.

Rosler^^ records two cases in which, after ;i;-ray treatment and arsenic
had been tried without success, benzol given by the mouth led to extra-
ordinary, even if only temporary, improvement. It is apt to produce
diaiThoea and vomiting if the dose is pushed to more than a moderate
extent, but some patients are able to take as much as a drachm ,of
benzol per diem and continue with this for -weeks at a time without any
untoward effect upon the stomach, liver, or kidneys. Rosier recom-
mends that chemically pure benzol should be mixed in equal parts with
pure olive oil, the mixture being administered in gelatin-coated capsules.
Meyers and Jenkins^® also report a case in which good results were
obtained.

Jesperson^^ records a case in which the administration of benzol
by the mouth was followed by remarkable improvement in a patient
suffering from myeloid leukaemia that had reached an extreme degree,
with profound emaciation, anaemia, and fever, before the treatment was
begun.

Sohn^® has carried out a series of researches with a view- to deter-
mining what is the effect of benzol upon metabolism in the liealthy
body. He finds that it produces the same sort of alterations in the
oxidation processes in the body, and in the metabolism of sulphur,
as are produced b^' serious pathological conditions such as starvation,
cancer, cirrhosis of the liver, chloroform narcosis, and acute phosphorus
poisoning. He regards benzol as very liable to do damage to the
liver, and probably other organs as well, and sounds a note of warning
against its use in leukaemia except with the greatest caution.

Pappenheiin^'^ expresses the opinion that the action of either benzol
or benzine on the bone-marrow and blood-forming apparatus is neither
so elective nor so radical, nor so reliably constant, as is the effect of
radio-active substances ; he does not detiy that the action of benzol
influences the blood, but he regards the blood changes as deceptive, and
thinks the gastro-intestinal symptoms produced by the drug are due
to a damaging effect upon the mucous membrane which is not free
from danger.

References.* — hlin. Woch. 1913, 5O9 ; '^Milnch. med. Woch. 1913,
1981 ; ^Quart, Jour, Med, 1913, Apr. 293; ^Brist. Med,-Cdm, Jour, 1913, 10;

LEUK/EMiC ERUPTIONS

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MEDICAL ANNUAL

^BriL Med. Jour. 1913. i. 131S; ^Jour. Amey. Med. Assoc. 1912, ii, 1435;
nVie7L klin. Wach. 1913, 147; Mhid, 337; ^Ibid, 566; ^^Deut. med. Woch.
1913, 307; '^^JouY. Amey. Med. Assoc. 19x3, i, 495,’ ^^JVien. klin, Woch.
1913, 838 ; ^^Med. Rec. 1913, i, 823 ; ^^Deuf. med. Woch. 1913, 1300 ; "^^Wien.
klin. Woch. I9I3> 573 ; ^Mhid. 48.

LEUKJEMIC ERUPTIONS OF THE SKIN.

E. Graham Little, M.D., F.R.C.P.

Nanta^ reports a carefully observed case from Andry's clinique.
The patient, a woman, aged 54, showed much enlarged liver, spleen,
and mesenteric glands, and generally enlarged superficial glands in
the axillae and neck. The general health remained but little impaired.
The cutaneous eruption developed within fifteen days, and consisted
of very numerous tumours, some as large as a tangerine ; with macular,
papular, vesicular, pustular, and nodular lesions. The latter were
frequently surmounted with a vesicle or pustule, and were extremely
itchy ; some of them became ulcerated and crateriform.

The patient suffered much from the heat and from polyuria and
polydipsia, as well as from pruritus ; the latter was relieved by one
treatment of ;ir-rays. Blood examination showed 21,700 white cells
to 4,000,000 red; lymphocytes, 65 per cent; polynuclears, 17 per
cent. Sporotrichosis, which was suggested by the ulcerated nodules,
was excluded by bacteriological examination.

Treatment. — ^Besides the indications for treatment offered by the
general disease, the principal cutaneous symptom is pruritus, which is
sometimes excessive. Applications of X-rays are the best means of
combating this.

Reference. — '^Presse Mid. 1913, 361.

’ LINITIS PLASTICA— (6V5 Stomach, Fibromatosis of.)

LIPODYSTROPHIA PROGRESSIVA. Herbert French, M.D., F.R.C.P.

This name is given by Parkes Weber^ to a clinical condition, mainly
confined to the female sex, characterized by progressive disappearance
of the subcutaneous fat from the face, upper extremities, and trunk,
whereas the fat of the lower extremities and gluteal regions remains
unaffected or is increased in amount. In some cases, perhaps, the
condition is one of pathologically altered distribution of fat rather than
of genuine wasting, or possibly merely of relative excess of fat in the
lower extremities and buttocks of an othervdse rather thin subject.
Probably all degrees of this abnormal fat distribution occur, pro-
gressive in some subjects, and arrested or stationary in others, whilst
in yet other cases the condition may perhaps occur as only a temporary
feature in the life-history of a patient, or as -little more than a
slight exaggeration of a normal female sex character. In this connec-
tion it must be remembered that the development of subcutaneous fat
is greater in the thighs and gluteal regions of the average human female
than of the average male. The wasting of the face and upper part of
the trunk first attracts attention, the wasting usually commencing in
the face, neck, and upper part of the thorax, and spreading gradually

NEW TREATMENT

341

LIVER

downwards. In some of these latter cases, the onset of the wasting may
be fairly sudden, and the disease may, for a time at least, be associated
with anorexia, neurasthenic S5?mptoms, and excess of knee-jerks and
Achilles -jerks. The symptoms may commence in quite early life, at
ten or thirteen years, or later on, up to between twenty and thirty
years of age. The disease, though it seems (at all events in its most
typical forms) to be confined to the female sex, does not appear to be
connected with any obvious disease of the thyroid gland or ovaries.
In a sense it might certainly be called a “ trophic disease,’' but it is
of uncertain origin, and no successful treatment has yet been
discovered for it.

Weber has collected a number of illustrative cases from the literature,
and points out that some at least of the cases recorded as bilateral facial
atrophy have nothing to do with facial paralysis, and are probably
examples of lipodystrophia progressiva.

Reference. — Med. Jour. 1913, i 1154.

UPS, SEBORRH(EIC KERATOSIS OF. E. Graham Little, M.D., F.R.C.P.

Sutton^ describes this as a circumscribed, painless, pigmented,
warty growth developing on senile skin or skin undergoing senile
changes. A roughened, scaly, brown or yellow plaque is formed,
which may persist for years, and may become epitheliomatous.
Sutton reports seven cases, in five of which the same treatment was
adopted, namely, application of X-i»ays (7 to 20 exposures, a medium
tube at a distance of 15 cm., treatments of eight minutes at weekly
intervals), followed by 5 per cent Salicylic Acid Ointment, and a final
treatment for one minute under heavy pressure with Solid Carbon Dioxide.
One case was treated with crystals of Trichloracetic Acid. The seventh
case threatened a rapidly developing epithelioma and was operated upon,

Reference. — '^Jour. Amer. Med. Assoc. 1913, i, 1774.

LIVER, ABSCESS OF. {See Amcebiasis.)

LIVER, CIRRHOSIS OF. Robert Hutchison, M.B., F.R.C.P.

Davis^ has had successful results from the use of a diet consisting
mainly of Milk, combined with the administration of Elaterium (J gr.
three times a day for the first day, and afterwards every night). He
is of opinion that a milk diet lessens dropsy and the tendency to hepatic
toxaemia. He also gives Urotropin to disinfect the bile-passages,
(See also Splenomegaly.)

Reference. — '^Jour. Amer. Med. Assoc. 1913, ii, 273.

LIVER, CYSTS OF. Sir Berkeley Moynilian, M.S., F.R.C.S.

Harold Upcott, F.R.C.S.

Non-parasitic cysts of the liver may, according to Boyd,^ be grouped
under two headings, (i) General cystic disease is generally associated
■with a similar lesion of the kidneys. The only surgical interest
attaching to it arises from the fact, that in some cases the largest of the
cysts has been dealt with by operation under the impression that it

LIVER

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MEDICAL ANNUAL

was a solitai-y one. (2) Solitary cysts are, as a matter of fact, not clearly
distingiiishable from the former condition, for in the tissue surrounding
a solitary ” cyst, other minute cysts are commonly found ; indeed,
it has been suggested that both forms have a similar origin.

Apart from the development of a fluctuating swelling in the upper
abdomen, which can generally be shown to be connected with the liver,
there are no very characteristic symptoms. There may be a slight
amount of pain in the hepatic region, and in several cases dyspepsia
and vomiting were present. Jaundice appears to be rare.

Operative Treatment is indicated in all cases of apparently solitary
cyst of the liver ; and even ^vhen multiple cysts have been present,
considerable relief has been afforded by treatment of the largest. If
the cyst is superficial or pedunculated, resection is desirable; but if it
is intrahepatic, incision and drainage, or partial resection with suture
of the edges of the cyst to the paidetes (marsupialization), is the safe
proceeding. Boyd gives an extract of 33 cases from the literature
and reports one of his own, the patient dying three months after
operation from peritonitis, after having the sinus syringed with
hydrogen peroxide.

Reference. — ^Lancet, 1913, i, 951.

LIVER, FUNCTIONAL DERANGEMENT OF.

Robert Hutchison, M.D,, F.R.C.P,

Bain^ points out that comparatively little attention has been devoted
to functional affections of the liver, the chief causes of which he sum-
marizes as follows : dyspepsia, gastro-intestinal disturbance, alcoholic
excess, rich and highly-seasoned food, fevers, nervous influences, and
residence in the tropics.

Treatment. — The best method is to diminish the amount of work
the liver has to perform, and to facilitate the circulation through it.
The work of the liver depends chiefly upon the quantity and composi-
tion of the food; therefore, in order to restore normal hepatic function,
there must be a limitation of the food supply ; but it must be borne in
mind that too rigid a dietary may interfere with the nutrition of the
liver cell, and thereby injuriously affect its activity. The restriction
in the quantity of food should therefore be compatible wdth the main-
tenance of normal nutrition. A mixed diet is the best, the articles being
of simple composition. Three meals a day are advised unless the gall-
bladder is involved. Carbohydrates and fats should be limited, as the
former tend to ferment, and the latter are not easily absorbed if the
quantity of bile excreted is diminished. Alcohol should be forbidden.
Other irritants, such as mustard, pepper, red pepper, horse-radish,
ginger, cloves, strong meat broths, large quantities of salt, and the
empyreumatic substances that are formed in baking and roasting,
should be avoided. In most cases it will not be necessary for the
patient to exercise dietetic self-denial for more than a week. Rest
after meals should be enjoined, so that the functional hyperaemia of the
organ is not disturbed. Exercise such as golf is very important. With

NEW TREATMENT

343

LIVER

increased respiratory eifort the liver is rhythmically compressed, and
the venous blood flows more rapidly to the heart. For those unsatis-
factory individuals who take little or no exercise, massage, general and
special, is desirable.

Regarding drugs, he suggests a pill containing Colalin and Iridin, or
Podophyllin and colalin, at bedtime, followed by a dose of Sulphate of
Soda or Carlsbad Salts in the morning, for a week or longer. If the
stools are clay-coloured, Calomel may be substituted for either of the
pills.

Reference. — Med. Jour. 1912, i, 1117.

LIYER, FUNCTIONAL EFFICIENCY OF. O. C. Grimer, M.D.

A number of observations have been made relative to this subject,
among which the work of Strauss,^ Hohlweg,*^ and Gouget® niay be
quoted. The various methods of studying the adequacy of the liver
that have been employed in the past are : —

1. Estimation of the diminution of urea in the urine after adminis-
tering ammonia and amino-acids. The objection to this is that urea
is not made in the liver alone.

2. The appearance of ammonia and amino-acids in the urine. The
objection to this is that the degree of excretion is dependent upon the
variations of acidity of the organism as a whole.

3. Glaessner's test of giving amino-acids by the mouth and estimating
how soon they appear in the urine. This test has been verified by Falk
and Saxl and others.

4. Increased excretion of urobilin. The French authors consider
that urobilin is the product of a diseased liver cell, and the extent
of its appearance an index of the severity of the lesion.

5. The delay of appearance of camphor-glycuronic acid in the urine
after giving camphor by the mouth.

6. The well-known l^vulose test. Hohlweg finds that there is much
less tolerance for laevulose when there is a stone in the common bile-
duct, and also in catarrhal jaundice. This is valuable information
for the difierential diagnosis between urinary and gastric colic. There
is no change in metastatic cancer of the liver, unless the bile-ducts are
involved. Strauss gives an extensive analysis of the laevulose test,
being impressed with its value in diagnosis, and also advocates

7. The galactose test.

8. Certain indices : (a) Diminution of azoturic coefflcient-

Urea N

Total N

— should be at least 80 per cent. (6) Elevation of the ammoni-uric

. , ammonia N . , , , ^ _ , , v . r

coefficient — — ^ should be 2 to 6 per cent, (c) Appearance of

amino -acids in the urine, {d) Arthus* coefficient, that of urogenic

ammonia N , , ^

[e) Lanzenberg s coefficient of

defect :
acidosis

ammonia N x urea IST.
ammonia N 4- amino-acid N

ammonia, N -h amino-acid N -f urea N ’

-on a milk diet

LIVER

3^4

MEDICAL ANNUAL

is 4-18 ; on meat diet 6-31. In cirrhosis and cancer of the liver, in
diabetic coma, and some cases of obesity, it is very much raised. Gouget
further refers to the absence of a ferment in the blood that can reduce
glycogen to glucose. This again is an indication of functional
inadequacy of the liver.

References. — ^Deut, med. Woch. 1913, 17S0; ^Munch. med. Wooh, 1913,
2271 ; ^Presse Mid, 1913, 234.

LIYEB, SYPHILIS OP. Robert Hutchison, M.D., F.R,C.P,

McCrae^ believes that tertiary syphilitic affections of the liver are
commoner than is supposed. On the other hand, their recognition is
very important, as they lend themselves remarkably well to treatment.
From a careful study of fifty-six cases he concludes that syphilis of the
liver presents a very varied clinical picture, with prominent general
symptoms in many cases, of which loss in weight is marked. The
duration of the symptoms may be prolonged, and there may be periods
of improvement. Fever is a common occurrence. There are features
suggestive of hepatic disease in the majority of the cases. Enlargement
or tumour is the most common. This may suggest other conditions,
especially malignant disease. General enlargement, and the occurrence
of nodules or large rounded masses are the most usual. A striking
feature is the relatively marked enlargement of the left lobe as com-
pared with the right. The diagnosis may be obscured by other diseased
conditions, or the liver condition may be interpreted wrongly. Ascites
is sometimes a difficulty. Knowledge of the features of hepatic syphilis
and the therapeutic test are important aids.

Treatment can influence the syphilitic process, but not its results
(cirrhosis, amyloid). Iodide of Potassium alone gives splendid results,
but it is perhaps wiser to give Mercury as well.

Reference. — "^Amer. Jour. Med. Sci. 1912, ii, 625.

LOCOMOTOR ATAXY. {See Syphilis, Cerebrospinal.)

LUNG, SURGERY OP. (See also Empyema; Pneumothorax, Arti-
ficial.) Priestly Leech, M.D., F.R.C.S.

Morriston Davies^ has investigated Freund's suggestion that there is
a close relationship between apical pulmonary tuberculosis and
abnormal changes in the cartilage of the first rib. After a most pains-
taking research, he finds that neither abnormal shortness nor ossification
in the first costal cartilage predisposes to apical pulmonary tuberculosis ;
abnormal shortness does not encourage its ossification, which is
dependent on age and sex, and probably occupation. With increasing
age there is increasing limitation of movement of the sternal angle ;
this, however, does not predispose to apical pulmonary tuberculosis.
The presence of a groove in the posterior external aspect of the lung
below the apex (Schmorl) is not the result of abnormal shortness of
the costal cartilage, but probably of emphysema. The formation of
a false joint in the rigid cartilage does not tend to lead to the cure of
apical tuberculosis ; so that the balance of evidence is therefore against
the probability of benefit following such an operation.

NEW TREATMENT

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LUNG SURGERY

The same writer, ^ in a very complete article, reviews recent
advances in the surgery of the lung and pleura. It is impossible to do
full justice to it in a short abstract, but attention may be drawn to the
main points. Many think that the chief advance in this branch of
surgery has been in the technique of operations on the open chest as
illustrated by the discoveries of Sauerbruch and Brauer ; but this is
only applicable to a small number of cases. The result of progress in
lung surgery has been the emergence of three main lines of treatment,
which may be termed treatment by collapse, by consolidation and
iibrosis (solidification), and by excision.

Treatment by Collapse is the most striking advance in pulmonary
surgery, in that it is applicable to many pathological conditions, and
is an entirely original procedure applicable to no other part of the body.
Early and precise diagnosis is a sine qua non if treatment is to be
satisfactor5^ When air is introduced into the pleural cavity, the
oxygen is absorbedi but the nitrogen and carbon dioxide remain for
a much longer 'period. When collapse of the lung for therapeutic
uses is needed, as in phthisis, nitrogen is used, but when the object is
to mplace fluid and obtain expansion of a collapsed lung, oxygen is
^^^jntfoduced. In phthisis, nitrogen maybe used if the disease is unilateral,
and also in some cases where there is slight disease in the other side,
with enough healthy tissue to aerate the blood when the diseased
side is put out of action, Caseating pneumonia and rapidly progressing
miliary tubercle are not suitable for this form of treatment. The
dangers are two, viz., nitrogen embolism, and pleural eclampsia ”
or '' pleural reflex.” Nitrogen embolism is due to the needle entering
the lung and gas escaping into a blood-vessel. The ” pleural reflex ’*
may be caused by the needle puncturing the pleura, by the introduction
of nitrogen under excessive pressure in a part of the pleural cavity
localized by adhesions which are thereby dragged on, or by the rupture
of adhesions. Previous uneventful puncture of the pleura or rupture
of adhesions, offers no guarantee that the reflex will not occur on a
subsequent occasion. The phenomenon manifests itself usually as a
syncopal attack, with partial or complete loss of consciousness, marked
restlessness, pallor, and disappearance of the radial pulse. The
symptoms usually disappear in a few minutes, but death may ensue.
To avoid ” pleural reflex ” the parietal pleura should be anaesthetized
with novocain ; gas embolism may be avoided by using a water
manometer. Sepsis and pleural effusion are other additional dangers.
The results in phthisis have been encouraging, but the treatment
must be continued for a year, and fresh nitrogen introduced every
two or three months.

It has been known for some time that the aspiration of fluid from
the pleural cavity is not devoid of danger, and that even after an
apparent complete withdrawal of fluid there is still a good deal left
at the base. Morriston Davies has shown that if, during paracentesis,
whenever there is the slightest symptom of distress, loo c.c. of oxygen
are allowed to flow in, the distress ceases ; the whole of the fluid can

LUNG SURGERY 346 MEDICAL ANNUAL

be removed, and the lung can be cleared so as to permit of complete
radioscopy and radiography. The aspiration is done with the ordinary
apparatus, and the hollow needle for the gas is connected with the
same apparatus that is used for producing a pneumothorax in phthisis,
but filled with oxygen instead of nitrogen. The needle must have a
bore of at least i mm., in order that the intrapleural variations of
pressure may be transmitted through the fluid which surrounds its
opening. The cannula for aspiration is introduced into the lowest
accessible part of the fluid, and the needle connected with the oxygen
some two interspaces higher up. The fluid is drawn ofi until the first
indication of discomfort to the patient is noticed, when the aspiration
is instantly stopped and 100 c.c. of oxygen are slowly allowed to
flow into the pleural cavity. Aspiration is then renewed, till a slight
degree of pain or cough indicates that another 100 c.c. of oxygen must
be let in. This sequence is repeated until the aspiration sucks out
oxygen alone, when a final 100 c.c. of oxygen are run in to lower
the high negative pressure.

Mechanical Control of Open Pnemnothorax. — Opinions vary as to the
advantages of the hyper-atmospheric [iteherdruch) and hypo-atmo-
spheric {unterdruch) methods of differential pressure. Morristoii
Davies thinks that the Sauerbruch chamber with its negative pressure
{imterdnich) reproduces more nearly the normal physiological condi-
tions. Meltzer has introduced the insufflation ” method, which is
applicable for all operations, and not only for those in which the pleura
is opened. In this method, air at a pressure above that of the
atmosphere, and mixed with anaesthetic, is administered by a catheter
which passes down the trachea to a point immediately above its
bifurcation, while the escaping air passes out between the catheter and
the sides of the trachea and glottis.

Choice of Method of Ancesthetization for Operations on the Thorax , —
{See also Anesthetics). The opening and draining of an emypema,
the removal of ribs for bronchiectasis or chronic empyema, the
“ Pfeiler-Resektion ” of Wilms for tuberculosis, the removal of costal
cartilages for bronchitis and emphysema or for the opening of a
pericardial effusion, should all be done whenever possible under
regional or local anesthesia with novocain. For more extensive
intrathoracic operations, intravenous ether anesthesia offers many
advantages, and when using his hyper-atmospheric apparatus, Davies
considers this method preferable to all others. For inhalation anes-
thesia, chloroform is the least irritating, and should be used in prefer-
ence to ether.

Empyema. — In acute cases which do not close, the expansion of the
lung proceeds much more rapidly under the influence of aspiration
than by the use of ordinary methods. In chronic empyemata the
operations of Schede, Estlander, and Delorme, and Wilms’ “ Pfeiler-
Resektion,” are all useful. The treatment of fistula by means of
bismuth paste is failing into disuse, owing to the number of cases of
poisoning which have occurred. For radiographic purposes a 20 per

NEW TREATMENT

347

LUNG SURGERY

cent solution of collargol is quite efficient and is non-toxic. In cases
of calcification of the pleura, unless the calcified plates give rise to
symptoms, they should be left ; but if operation is undertaken, they
must be completely removed, otherwise a chronic sinus will develop.

Injuries of the Lung. — In crushes or blows without fracture of the
skeletal part of the thorax, lacerations with or due to fracture of ribs
and sternum, and penetrating wounds (bullet or stab), it is becoming
increasingly obvious that conservative treatment, when efficiently
carried out, gives the best chance of recovery. The indications for
interference are severe intrathoracic bleeding which increases in spite
of palliative measures and absolute rest, or, if arrested, is repeated ;
and progressive mediastinal emphysema. During operation the
pneumothorax must be controlled by some form of differential pressure
mechanism ; the pleural cavity is emptied of clot ; wounds in the lung
are stitched up with catgut, but extensively damaged portions must
be removed. Drainage is inadvisable. Absolute rest is a sine qua non
in the treatment, and it must be taken ‘in its most literal sense, as the
slightest movement may accelerate the haemorrhage or re-open a closed
vessel. Morphia should be given freely to quiet the patient.

Foreign Bodies in Lower Air Passages and Lung. — Removal by the
bronchoscope is the method of choice ; its failures may be due to
secondary changes in the bronchus and adjacent lung tissue, or to
the depth to which the foreign body has been inhaled. In the latter
case operation is indicated. The extra-pleural part of the bronchus
may be reached through a posterior incision, the lung and pleura being
displaced outwards. If the body is in the lung itself, transpleural
pneumotomy must be tried.

Abscess of Lung. — Statistics show that the mortality of this disease
is 8o per cent if left untreated, while after operation it varies from
34‘5 to 17*5 per cent. It has been much lower lately, thanks to advances
in radiology and the diminished danger of opening the chest in the
absence of adhesions by the use of a differential-pressure apparatus.
As regards operation, the route of approach is determined by the position
of the cavity, as shown by clinical and radiological examination ; the
pleura should be exposed over a wide area, preferably by the formation
of a fiap, and the ribs underlying this should be removed, so that the
chest wall will be more yielding, and will help to obliterate the cavity. If
the pleurse are not adherent, the parietal should be sewed to the visceral
pleura. Some surgeons do the operation in two stages, waiting for
firm adhesions to form before opening the cavity. Discovery of the
abscess is difficult unless the lung has been palpated. Exploration
with needle and syringe is justified only after the pleural surfaces have
been united. If pus is found, the needle is left in situ and an incision
made along it. If pus is not found, a gradually deepening crucial
incision is made, the vessels being ligatured as soon as cut. If the
abscess is ’not discovered, the wound should be plugged with gauze in
the hope that it will burst into it. When it is found, the edges of the
cavity should be stitched back and gauze plugging used. Secondary

LUNQ SURGERY

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MEDICAL ANNUAL

hemorrhage may occur ; this must be treated by packing with gauze,
and morphia. If empyema is associated with the abscess, the prognosis
is very grave. The empyema must be treated first, and then the abscess.

Solidification of the bung is the basis of the surgical treatment of
bronchiectasis and tuberculosis. The methods of producing this are :
(i) Temporary collapse by introducing nitrogen into the pleural
cavity ; (2) Production of permanent consolidation of (a) part of the
lung by rib resection, division of the phrenic nerve, or ligature of the
pulmonary artery ; (b) of the whole lung, by resection or mobilization
of rib. In bronchiectasis all have been tried, and a bronchiectatic lobe
has been amputated several times. The mortality of extensive rib resec-
tion is high and the cures are few, Sauerbruch has ligatured a branch
of the pulmonary artery seven times, with most encouraging results,
Wilms’ operation of rib mobilization {'* Pfeiler-Resektion ”) is used
for cases of pulmonary tuberculosis in which the intrapleural collapse
ol the lung is impossible. The principle of the operation is the removal
of portions (2 to 3 cm.) of the posterior ends of the upper seven or nine
ribs, and of the costal cartilages of the first five or six ribs, the essential
feature being the mobilization of the first rib : unless this is done the
operation is valueless. In streptothricosis and in new growths of the
lung, surgery may intervene in some cases with success : Davies
reports one case which went well for six da^^’s till an empyema developed,
which was fatal on the eighth day.

He found infiltration of the vagus with novocain very useful.

A good deal of discussion has taken place as to the treatment of
penetrating wounds of the lung. Von Kutscha® discusses the whole
subject, and reports four cases in the hospital at Vienna. All were
operated on, and three recovered ; one was diagnosed as a wound of
the heart. The diagnosis as to whether the lung is wounded or not is
very difficult and often impossible. The clinical symptoms are dullness
of the lower part of the thorax, pneumothorax, emphysema of the skin ,
hsemoptysis, difficult and quick respiration, and the general signs of
anaemia ; but all these symptoms may be due to an increasing pneumo-
thorax. Haemoptysis may not be present even with a bad wound of
the lung. His conclusions are that serious hsemorrhage and collapse
of the lung in consequence of a pneumothorax justify an operation
even without differential pressure ; if operation is done, a sufficiently
wide opening in the thorax must be made, and the wound in the lung
must be stitched before a pneumopexy or artificial inflation of the
lung is carried out.

Kellock^ reports a successful case of pneumotomy for a shawl pin in
the lung of a child, aged 4 J years. The pin was about two inches long ;
the skiagram showed it at the level of the third rib on the right side,
apparently in the right bronchus, wdth the point upwards. The day
after admission several attempts were made to remove the pin through
the bronchoscope, but although the forceps grasped the pin it could not
be lifted a\vay. Later on the skiagram showed the pin to have travelled
nearly to the diaphragm. The technique was as follows : A square

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LUPUS ERYTHEMAtOSUS

4-inch flap was made consisting of skin and superficial muscles, and
reflected backwards ; the edges of the flap were parallel to the direction
of the ribs, the posterior ends of the upper and lower incisions
reaching to within an inch of the middle line of the back, the marks of
localization being used as guides as to the level at which to open the
chest. Four of the ribs were divided subperiosteally at the anterior
part of the wound. The deep muscles of the back were thus retracted
towards the middle line, and the same ribs were cut with bone forceps
as far back as they could be reached, the forceps being passed close
above and below the bones. The intercostal muscles and ribs were
divided along the anterior ends of the cut ribs in the whole length of
the wound, and above and below the divided ribs, and the flap turned
backwards, a window about 3 in. square being thus formed. The
diaphragm bulged up into the w’ound and w-as kept down with a flat
retractor. With a finger passed between the lung and diaphragm it
was thought that the pin could be felt. Two silk sutures w’ere passed
through the edge of the lung to hold it in position against the chest w^all,
but they w^ere not of much use. An incision was made over the place
where the hard lump w^as felt, but wdien any attempt w^as made to
introduce the finger, the lung receded. Two fingers of the left hand
introduced into the sulcus between the middle and upper lobes of the
lung pulled the lower lobe outwards and steadied it, and the needle was
then easily felt and extracted. The w^ound of the lung was closed by a
silk suture, and the two flaps sewn in place, with a small drainage tube
at the anterior inferior angle passed down to the wound of the lung.
Very little discharge came from the tube, and it was not offensive after
the second day. The child had coughed some offensive matter up, and
a small quantity of offensive pus had escaped w^hen the lung was incised.

References. — Jour, Surg. 1913. July, 55 ; Oct., 228 ; 'HVien,

klin, Woch, 1913, 737; ^Lancet, 1913* i 92.

LUPUS ERYTHEMATOSUS. E, Graham Little, M,D„ F.R.C.P,

Etiology. — MacLeod^ dwells especially on the varieties, nature,
causation, and treatment. Clinically, the tw^o types of discoid or
fixed chronic patches, and the acute disseminated form, are to be dis-
tinguished. It is possible that these may really be distinct diseases, for
the impression found much support in the subsequent discussion, that
lupus erythematosus is not a single entity, but that “persistent erythema
succeeded by atrophic scarring. “ which may be regarded as the essential
features of the affection, may be the result of many different causes.
MacLeod, in common with most dermatologists, rejects the tuberculous
hypothesis, and inclines to the view that other toxins than tuberculous
are more often the determining factor. The similarity of the
symptoms, especially of the acute variety, to those of erythema
multiforme, is an argument for a similar causation, and the histological
characters of the two diseases are also similar.

The causes are predisposing and direct ; under the former heading,
adults almost exclusively are affected, more especially between the

LUPUS £RYTHEMATOSUS

350

MEDICAL annual

ages of 20 and 40 ; it is three times as common in women as in men ;
a defective peripheral circulation is almost the rule, and may be the
result of anaemia, heart disease, tuberculosis, or rheumatism. Of the
dived causes, toxins of unknown nature, but possibly derived from
the intestinal canal or from disordered visceral functions, are assumed
to play the chief part, aided by local factors determining the incidence
of the lesion, e.g., frost-bite, cold, insect-bite, sunburn.

HartzelP has recorded and collected a series of cases of lupus
erythematosus in association with Raynatid's disease. He considers
this relationship may best be explained by supposing both to be due
at times to a common cause, most probably a toxin circulating in the
blood, which acts primarily upon the vessel walls, producing vasomotor
and inflammatory changes in the skin and subcutaneous tissues.
Erythematous lupus should therefore be regarded as a toxic erythema.

Treatment. — This, says MacLeod, must vary with the type of disease
present. Active local interferences with the acute variety should never
be attempted ; in these cases, fortunately much less frequent, internal
antitoxic agents such as Quinine, Salicin, and Ichthyol are chiefly
relied on, and the patient should usually be kept in bed. In the
discoid or fixed type, local treatment may be properly undertaken,
and the author prefers Ionization with Zinc Salts, a 2 per cent solution
of zinc sulphate with a current of 2 to 5 milliamperes for fifteen minutes
at a sitting being recommended. Freezing by Carbon Dioxide Snow
should be used only for the fixed chronic patches, and exposures of
only 5 to 10 seconds with medium pressure used. A'-rays, radium and
Finsen are usually disappointing in their results. Various lotions and
pow^ders are also useful, especially in reducing hyperaemia : thus equal
parts of Zinc Oxide and Magnesium Carbonate may be dusted on the
inflamed area ; or Calamine Lotion or Lassar's Paste with or without
ichthyol may be applied. Collodion Flexile with i per cent Salicylic
Acid, applied several times a day, mechanically reduces congestion.
In the subsequent discussion, Wild suggested the use of Iodide of
Mercury to dissolved in water with 3 to 5 gr. potassic iodide,

and given three or four times a day in the acute variety of the disease.
In ,very chronic cases, Davis was satisfied with the advantages of
Multiple Galvano-puncture as recommended by Sabouraud. Winkelried
Williams, considering the incriminated toxins to be usually of alimentary
origin, deprecated the use of powerful hydragogue purgatives, which
might release an overdose of the toxin from the faecal content of the
bowel. [See also Skin, General Therapeutics of.]

References. — 'RnV. Med. Joiiv. 1913, ii, 313 ; ^Amev. Jour. Med. Sci.
1912, ii, 793-

MALABIA. Leonard Rogers, M.D., F.R.C.P.

S. R'. Christophers^ has made a notable contribution to the vexed
question of the description a/nd classification of anopheles. He has
carefully studied the variations in their colour marking, including
that of the wings, antennas, and legs, and compared these with the scale

NKW TREATMENT 35 ^ MALAI^IA

characters on which Theobald mainly based his classification. The
two agree fairly closely, and a scheme of phylogenetic arrangement,
showing gradual elaboration of ornamentation and scale development,
is worked out. This again is shown to correspond in a general way
with the geographical distribution, and thus appears to be of distinct
scientific value. Finally, an elaborate table, showing the grouping of
species of anophelinse according to colour and markings and other
variable characters, is given. The paper is illustrated by good plates,
but the detailed character of the anatysis does not lend itself to further
abstraction.

D. Thomson ^ has continued his numerical blood examinations in
malaria. He finds a decrease of leucocytes during malaria, but during
early convalesence they may be slightly increased, which he thinks
is due to the presence of very small numbers of parasites. This
is supported by the counts after injection of certain numbers of dead
parasites. Crescents gradually become reduced, and usually disappear
within three weeks if 20 gr. of quinine are given daily, by which means
further formation of crescents is prevented and they die out. He
thinks the ideal method of quinine prophylaxis would be to give such
doses for three weeks in each quarter of the year to the whole population
in malarious places, children receiving proportionately smaller, doses,
and he suggests that this plan would be preferable to 5-gr. doses daily
throughout the year.

T. F. G. Mayer^ describes and figures a mosquito- and storm-proof
house for the tropics, and especially for West Africa. It is made by
Messrs. Humphreys, Ltd., of Knightsbridge, of steel with a minimum
of wood. In order to allow of some breeze, there are no walls or
partitions within the house, the occupant using screens and curtains
for dividing the space.

Cultivation of the Malarial Parasite. — C. C. Bass and F. M. Johns, ^
of the Tulane (New Orleans) School of Tropical Medicine, have made
the important discovery of a simple method of cultivating the malarial
parasite. Ten c.c. of blood are withdrawn from a vein and defibrinated,
and 0*1 c.c. of a 50 per cent solution of dextrose is added. This
is incubated in a tube containing a column at least two inches in
depth at not less than 40° C., preferably at 41® C. There should be
at least half an inch of serum above the corpuscles after the blood has
settled. The parasites are found in the upper one-fifteenth to one-
twentieth of an inch of the corpuscle layer. If a second generation is
to be grown, the leucocytes must be removed by the centrifuge, or the
extra-corpuscular spore forms will be destroyed, and the subculture
should be made within six hours of sporulation. By this means four
generations have been obtained. All three forms of malarial parasites
have been grown, the organisms increasing in size and segmenting,
and the young forms entering fresh red corpuscles. The asexual cycle
does not differ in culture from that in the human subject, but the
sexual stage has not yet been obtained in the culture tubes. The
temperature greatly affects the grow^th, which is much slowed by

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352

MEDICAL ANNUAL

several degrees below the optimum, when the tertian variety may take
as long as four days to complete the cycle. Some forms suggesting
parthenogenesis have been observed. J. G. Thomson, D. Thomson, and
H. B. Fantham^ have partially confirmed Bass's observations by
cultivating one generation of benign tertian parasites up to the stage
of sporulation from young ring forms. The maximum number of spores
was sixteen. H. Ziemann® also obtained undoubted development of
the tertian malarial parasite by Bass's method.

Mary Rowley-Lawson^ deals with the relationship of the malarial
parasite to the erythrocyte, and thinks that it is attached to the outer
surface and not intra-corpuscular.

A. Balfour® records a further year's anti-malarial work at Khartoum,
with an illustrative map. A vigorous mosquito crusade was maintained,
but difficulties arose owing to the fall of the river leaving sandbanks
with numerous pools which were difficult to deal with. Moreover, the
mosquitoes were found to travel longer distances than was formerly
thought ; and he now concludes that in future it will be absolutely
necessary at low Nile to include within the inspection area a point at
least two miles from Khartoum as the crow flies. Trains were found
to carry the insects on a considerable scale, as well as steamers and
boats. Half the annual malarial prevalence occurred in September.
No benign tertian cases were met mth. Sanitas-okol was found best
as a larvicide. For fumigating ships, Cresyl was employed. Mosquito
traps were used in houses.

N. P. O'Gorman Lalor® describes and illustrates in colours what he
considers to be spore forms incorporated in the nucleus of large mono-
nuclear cells, which he observed in malarial fevers in an area of Burma
in which blackwater fever occurs.

J. M. Woolley^® describes, under the head of malaria, a fatal form of
fever with marked jaundice in -which he found no malarial parasites. It
occurred in the Andaman Islands, and may, he thinks, prove to be a
new non-malarial fever. The symptoms closely resemble those of
malignant jaundice accompanied by haemorrhages, and the death-rate
was 40 per cent. Quinine was useless in the treatment.

J. M. Atkinson^^ found the presence of traces of urobilin in the urine,
as demonstrated by Schlesinger's reaction, of great diagnostic value in
malarial fever, even when parasites could not easily be found in the
blood. The test can be rapidly performed. It may also occur in liver
abscess, etc., but a negative result speaks strongly against acute
malarial fever. Schlesinger's solution consists of zinc acetate i part,
alcohol 10 parts. An equal quantity is added to urine in a test-tube
after being well shaken. A few drops of a weak solution of tincture
of iodine are added, and the mixture filtered, when a more or less
distinct fluorescence indicates a positive reaction.

J, P. Bates^^ deals with malarial anjemia. He confirms Dionisi and
others in finding a rapid loss of red corpuscles, followed in chronic cases
by a considerable rise in the numbers, due to tolerance to the toxins.
Insufficient food, or the presence of hook-worms, greatly intensifies

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MALINGERING

the anaemia. The term malarial cachexia is misleading and ought to
be dropped.

■ E. Marchiafava^^ deals with pernicious malaria, all of his cases from
1885 onw^ards having been due to malignant tertian parasites, and
never to benign tertian or quartan. The cases are fresh primary
infections with soft spleens, and the parasites increase rapidly until
there may be more than one ring in each corpuscle. Quinine in full
doses, either subcutaneous^ or even intravenously, may often fail to
avert death, the parasites being very resistant and showing irregular
development, the end being due to the central nervous disease. Healthy
workers in malarial regions should take quinine from the very first
symptom, the blood being frequently examined in doubtful cases,
Ross’s thick film method being useful.

Treatment. — H. Werner^^ finds both Salvarsan and Neosalvarsan
effective against benign tertian malaria, but not against the malig-
nant tertian form. E. E. Waters^^ has used Amorphous Cinchona
Alkaloid with success in malaria. This is a mixture of amorphous
alkaloids of cinchona bark, which was named quinoidine by Seturner
as long ago as 1830.

References. — ^Ann. Trap. Med. and Hyg. 1913, 45; 1912, 215 ;

Ibid. 1913, 223 ; ^Ihid. 1913, 41 ; ^Jour. Exper. Med. xvi, 567 ; ^Ann. Trop.
Med. and Hyg. vi, 449 ; Ibid, vii, 153 ; ^Deut. med. Woc/i. 1913, 260 ; "^Jour.
Exper. Med. 1913, No. 3 ; ^Jour. Trop. Med. 1913, 225 ; ^Ind. Med. Gaz.
I9i3i 253; ^^Ibid. 266; ^Mancet, 1913, i, 1802; ^^Jour. Trop. Med. 1913,
209 ; ^M)eut. med. Woch. 1913, 1577 ; med. Woch. 1912. 2068 : '^Und.

Med. Gaz. 1913, 89.

MALIK CERING. {See also Ear, Diseases oi^) Sir John Collie, M.D,

What is Malingering ? — A recent author has described a malingerer
as “ one who feigns sickness, or who (deliberately, knowingly and
wilfully) induces or protracts an illness with the object of evading
duty, claiming money compensation, exciting sympathy, or from
any other reason.”

Necessity for Detection of Malingering. — Many serious errors in
diagnosis are made in ordinary practice, not from ignorance, but
because the disease which has been missed is one which is either
rare, or seldom met with by the practitioner concerned. It is in this
sense only that malingering is difficult to diagnose. In ordinary
practice, until the present time, simulation of disease has been
practically unknown ; but most of us — at any rate those who have
panel patients — must, if justice is to be done, be keenly alive to the
possibility of patients remaining unduly long on the sick list. It is
unfortunate that an atmosphere of suspicion, however impalpable,
must be sometimes present when dealing with the insured. Neverthe-
less, those who have panel patients must safeguard themselves from
the many pitfalls w'hich the malingerer prepares for the unwary.

The temptation to remain long on the threshold of work must in
many instances be very great. Many working men when ill receive
from various clubs a sum equal to, if not greater than, that which they

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35*1

MEDICAL ANNUAL

eani when well ; and when the National Insnrance Act adds to this
another 5s., 7s. 6d., or 10s. as the case may be, it is not difficult to
understand why certificates of sickness should be greatly sought after.
It is only fair to say that, even in the working classes, some men and
many women are unduly introspective, and in dealing with them, that
practitioner who best understands the environment of his patient,
makes due allowance for psychical conditions, abandons rule-of-thumb"
method of giving drugs, and substitutes for it the modern methods
of psychotherapeutics, will have fewer tussles with exaggerated or
so-called fraudulent claims.

The Medical Examiner. — In the detection of malingering, the mental
equipment of the examiner is one of the most important factors : he
must be open, frank, and fearless ; he should be kind yet firm. Unle-s
he is alert beyond all telling, and possesses, as most medical men do,
a wide knowledge of human nature, he is not likely to be very
successful.

General Conduct of the Examination, — The examination often
resolves itself into a battle of wits : the examinee has usually had an
opportunity of carefully thinking over and planning his method of
attack, whereas the medical examiner is only too often in the position
of defendant. Always watch a patient when he is entering the room ;
carefully observe him when he is undressing and dressing, but do so
if possible unobservedly. When the patient tells the story of his
wrongs and his pains, always tie him down to a definite statement.
Speaking generally, the more indefinite a patient’s statement is, the
more suspicious the case. There are obviously many and wide excep-
tions to such a general proposition ; but in dealing with those who are
malingering or exaggerating, I am confident from a very large experience
that it is wise to be suspicious of those who will not tie themselves
down to a specific statement of their complaints. Observe carefully,
therefore, the definiteness or indefiniteness of his allegations of pain
and disability. It is a wise precaution to note these in wiiting at the
time, if possible in his own words.

Much may be gained from making a tentative suggestion with
regard to return to work. I am always suspicious of the man who,
in a hopeless way, will give no idea of when he expects to be able to
return to work, and, as far as I am concerned, it never assists his case
if he adds, as such people frequently do, that he will return to work
when his own doctor says he is fit for it.

The physical examination of a patient for the detection of malinger-
ing can follow no set rules. The exigencies of each case can only be
learnt, and the difficulties met as they arise, by experience. Speaking
generally, the simplest methods are the best. Straws show how the
wind blows. I have often exposed a fraudulent limp by a careful
examination of the soles of the boots. One cannot limp persistently
without causing some difference in the wear of the sole of the boot.
The late Dr. Rose tells the following story. He was detained for
some considerable time in an anteroom whilst the patient whom he

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MALINGERING

was about to examine for an insurance company was being prepared
for his visit. He noticed a pair of boots on the floor, and, suspecting
that the claimant was really undressing and getting into bed, asked if
they were his, and putting his hands into them found they were warm 1

Thoroughness is the keynote of every examination. Never forget
that during the short half-hour in which the patient is being examined,
the medical man's reputation may be made or marred, and that facts
then ascertained, or points missed through w’ant of thoroughness,
may come up in judgment against one before lay committees or in
courts of justice. My advice to anyone who has not the time to do
this work thoroughly is, very emphatically, not to do it at all, not
only for the sake of those who employ him, but for his own sake. If
in doubt, every modern method of examination should be resorted to
before an opinion is formed. The author makes it an invariable rule
to have all difficult cases A'-rayed before forming an opinion. One
must not forget that if this be omitted, the medical man who is support-
ing the claimant may do it, to one's own discomfiture. A single Ar-ray
photograph of, say, a joint, is comparatively valueless ; the corres-
ponding joint should, if an abnormality be found, always be ;i;-rayed
for the purpose of comparison.

Stiff and Painful Joints. — It is often exceedingly difficult to get
patients tp relax their muscles for the thorough examination of a joint.
A little time spent upon the sound joint in showing the patient exactly
what is required is sometimes of much value. It is often useful to
explain to a patient that the mere process of keeping a joint stiff
involves muscular action, and that by examining the muscles in the
neighbourhood of the joint the examiner can, in fact, tell by their hard-
ness whether these are being brought into play. An old lady who
had been wearing a knee splint for many weeks declared very
emphatically that she could not bend the knee. She was unmasked
by the simple process of engaging her in an animated and interested
conversation as to the details of the accident, and suddenly asking her
to remove the boot of the foot on the afflicted side. She saved me
much trouble, and entirely gave away her case, by unconsciously
bending her knee and removing her boot in the ordinary way.

If it be a joint that is alleged to be painful, by absorbing the patient
in interesting conversation (I generally choose such a subject as the
notice he gave at the time of the examination, the number of witnesses
who were present, etc., surely a legal, and not a medical matter!), a
gentle and gradual movement of the joint will often betray the fact that
it can be moved painlessly. I well remember a case of a healthy man
who had fractured his clavicle some three months before, and who
was living comfortably upon the funds of an insurance society. He
had for many weeks convinced his doctor that he was absolutely
unable to raise his arm above a right angle with his body. A somewhat
limited examination convinced me of the falsity of his statements.
It was, however, a matter of the greatest importance that I should be
able also to convince his medical attendant. The patient was told in

malingering 356 MEDICAL ANNUAL

a casual way to strip to the waist, and to my amusement, and I confess
satisfaction, he removed a somewhat tightly fitting undervest in the
same manner and with the same alacrity that most show in taking
off a jersey after a football match.

When examining a patient*s capacity to^ raise his arm above his
head, his attention should be directed away from his alleged injured
shoulder or arm, on the pretext of examining his back ; his hands
should be placed resting lightly on the back of a chair ; he should be
induced to step backwards gradually away from the chair, his back
being thus straightened and his arms extended until he is in practically
a horizontal position. His hands are now actually high above his head,
although he may not realize this until he is suddenly told to stand
upright in front of an adjacent mirror, without being allowed to
move his arms.

A useful test for alleged weakness of the arm or shoulder is as
follows : The patient is induced to hang by both hands from a small
trapeze which is attached to the ceiling of the consulting-room and
suspended above the ground by means of a block and tackle. In case
it should be contended that he holds to the trapeze by the strength
of the unaffected limb, a cross-bar is taken and placed loosely through
the triangle of the trapeze, and he is instructed to hold on to each
end of the cross-bar. He is then again lifted off his feet. If he is not
able to use equal strength with both hands, this is at once apparent,
because the loose bar at once slips sideways through the triangle.
When the loose bar is maintained equably, the patient should then be
weighed, and one is able to state that he can suspend half his weight,
whatever that may be, with the alleged injured limb.

Many of the examples described are explained in fuller detail in my
book.^ The following is an interesting quotation, “ The patient
tried to make one believe that when the fist was closed, the. ring finger
could not be closed as tightly as the other fingers, and that there was
no power of grasp in that finger. He appeared to be a curious mixture
of simplicity and artfulness, and it was some time before I was able
to prove that he was affecting a disability which did not exist. . .
On being requested to lift by the semicircular handle a gipsy coal-
scuttle, weighing 28 lb,, he at first refused even to try, but after
considerable insistence was persuaded to make a serious effort. He
complained that the brass handle hurt the front of the ring finger.
. After the handle had been covered with cotton-wool, he was induced
to hold it up with the ring finger alone, but even then declined to try
to lift the scuttle off the ground. I said we would try it together, and
applying both my hands to his forearm, whilst he kept the ring-finger
acting as a hook, we pulled together, lifting the scuttle off the ground.
It is obvious that my assistance was merely a pretence, inasmuch as,
although I did help to pull, I could not possibly help him in keeping
bent the ring finger, upon which the whole weight was suspended.
His remark after this performance, * But you helped me,' showed that
he had been deliberately pretending incapacity. Six weeks later, as

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357

MALINGERING

the applicant did not appear at the hearing, the Judge terminated
the compensation, but it was arranged that the case might come on
again for trial a fortnight later. Meanwhile the applicant was said to
‘have heard of a job, which he decided to take, and abandoned his
claim three days before the date appointed for the further hearing. “

When a man complains of continuous pain in the neighbourhood of
a joint as the result of traumatism, one thinks of synovitis or osteo-
arthritis. Both these conditions are accompanied by wasting of the
muscles, with a reflex nervous action. A well-clothed muscular joint
said to be stiff, and the condition reported as having lasted for many
weeks, would on the face of it make one very suspicious. Not
unnaturally one has the impression that a man is himself a better
judge of the amount of pain he suffers than even his doctor, and it
is very difficult to deny the existence of pain when a patient alleges
repeatedly and positively that it does in fact exist ; but not infrequently
one is driven to judge to a large extent by outside circumstances.

Sciatica is often complained of, either without any basis of fact,
or when it has long since passed off. In the case of a man who alleged
this disability, I bared his leg, flexed his ankle, and held his foot a little
way from the ground, keeping the knee straight, and asked him to say
whether he felt a pin prick on- the inner or outer side of the foot. His
attention being thus distracted, I gradually brought the foot higher and
higher, still keeping the knee straight, until his leg was in a position in
which the sciatic nerve was considerably stretched. He made no
complaint of pain along the course of the sciatic nerve, which he must
inevitably have done had there been any sciatica present. I then told
him what had been taking place, and proceeded to flex his knee and
raise his leg upwards towards the abdomen. Now in this position the
sciatic nerve is not stretched, inasmuch as the knee is bent. But he in
his ignorance of anatomy thought I was again stretching the nerve,
and at once called out as if in pain.

Congenital Asymmetry, — I have had a few cases in which, after a
slight accident, disability has been alleged for long periods of time,
out of all proportion to the severity of the original traumatism, and
where the contention of incapacity is supported by the exhibition of
a limb which is obviously less muscular than the corresponding one,
a suggestion which is supported by the tape measure. The condition
is a somewhat embarrassing one to deal with.* When this is found
both in the upper and lower extremity on the same side, and when
the patient complains, as so frequently he does, of loss of muscular
power on that side, a diagnosis of paralysis is almost invariably made,
and this is frequently asserted to have been caused by an injury to,
say, the shoulder, back, or even a limb. If careful measurements are
made, many of these cases will be found to be suffering from congenital
asymmetry, and the accident has merely brought into prominence a
condition which the patient was either totally unaware of, or to which
he paid little heed until it was discovered that it had a latent monetary
value.

MAUNQERINO

358

MEDICAL ANNUAL

Congenital asymmetry is much more common than is supposed.
Careful, accurate, systematic measurements by means of an ordinary
tape measure are important. The value of these, however, depends
upon whether the corresponding limb on the other side of the body'
is also measured for comparison. Young found 70 per cent of unequal
limbs, the greater majority being larger on the right, and in his measure-
ments he excluded those having obvious disease such as flat-foot,
coxa vara, infantile paralysis, and so forth. The condition is supposed
to be hereditary. It may be that its origin is connected with a
difference in size of the main artery of supply of the limb. But the
lesson is that it is of the greatest importance to take careful circum-
ferential measurements of the limbs at different spots, and also the
following : from the sternal notch to the internal malleolus on both
sides, from the sternal notch to the anterior superior spinous process
on the right and left, and from the anterior superior spinous process
to the internal malleolus. When these are set out in diagrammatic
form, a surprising result will often be obtained. Tubby, in his

Abnormalities, including Diseases of the Bones and Joints,” has
gone into this matter very thoroughly.

Loss of Sensation is a symptom frequently complained of. A woman
who suggested that as the result of injury she had lost sensation in
her left leg, was asked to bare both legs, and her eyes were covered
with a handkerchief. I then pricked her right leg with a pin, asking
her to say ” Yes ” every time I did so, and she followed this instruction.

I then told her to say No ” every time I touched her left leg, in which
she had stated there was no sensation. More than a dozen times I
pricked each leg alternately, and she at once responded '* Yes ” to
the right and ” No ” to the left. This was fairly conclusive evidence
that she had sensation in both her legs.

Examination of the Back. — ^A stiff, painful back is a usual complaint
both with the out-and-out malingerer and the man who labours under
an obsession to this effect. When disease exists in the spine, the first
thing that nature does is to prevent movement, and pain consequent
upon it between each individual vertebra. In the case of a man who
absolutely declined even to attempt to bend his back, at the commence-
ment of the examination, I induced him later to touch his toes several
times ; each time putting the points of my fingers between the spinous
processes of the vertebrse which were supposed to be stiff, it was found
that as he assumed the erect position they moved freely one on the
other. No disease, inflammatory or otherwise, was present over the
alleged painful area, for, if there had been, the vertebrae would not
have glided upon each other each time he stood erect.

Another man persistently kept his back curved forward, and stated
that he was quite unable to straighten it. Such a disability, if genuine,
would certainly cause much pain if the back were forcibly straightened,
and would indeed be indicative of serious spinal disease. During the
examination he was induced to strip, and asked to lie flat upon a long
sofa. He did so with very little protest. Part of his clothes were

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then taken and rolled up in a good-sized bundle and placed under
the small of his back, thus actually arching his back in exactly the
reverse position to that in which he stated he was obliged to hold it
when walking. Still he made no complaint.

The painful back, the old “ railway spine of Erichsen, and the
"concussion of the spine" of modem times, is, in ninety-nine cases
out of a hundred, not a physical condition, but a neurosis born of much
morbid introspection, aided and fostered by covetousness. No one
knows better than the working man the difficulty that we doctors
have with subjective sensations, and especially when these are referred
to so complicated a structure as the spinal column. " When yer gets
hirt, say it's yer back ; the doctors can’t never get round yer back."
A worldng ,man told my friend the late Dr. Biss that he had received
this advice from a comrade prior to medical examination.

There are many physical signs which can be elicited when there is
disease of the spinal column. For instance, if when the patient’s
pelvis is fixed, and he is asked to move from side to side, he does so
without complaint, it goes a long way to prove that there is no disease
of the spinal bones. A test of like import consists of inducing him,
under pretext of examining first his right and then his left ear, to
twist his head, producing as it does a rotatory movement in a con-
siderable portion of the upper part of the spine. I sometimes ask a
man with alleged injury to the back to get up on his toes and come
down heavily on his heels. If he does this and complains of no pain,
an injury of any import may be put out of court,

Stifcess of the back is often proved to be non-existent by the
following simple manoeuvre : In the process of the examination, the
patient is asked to drop his trousers and pants to his ankles. In
the ordinary course, when a stiff back is complained of, this will be
done with great deliberation and apparent pain. But when, after a
thorough examination of the spinous processes, and some little time
spent in other ways, the patient is told suddenly and with some cheer-
fulness that the examination is over, he will often, with evident relief,
suddenly stoop down from the erect position with alacrity and pull
up his trousers. I well remember on one occasion I dropped my pencil
while examining such a case, when the stiff -backed one very courteously
and nimbly picked it up and handed it to me — a circumstance which
quite satisfied me, but not the jury who subsequently tried the case,
for the so-called patient absolutely denied all recollection of the
incident ! A friend of mine says that he occasionally drops a coin in
his consulting-room, in the hope that he may find his patient picking
it up. I have never resorted to this device, for it is open to obvious
disadvantages.

The mala fides of a patient may readily be exposed by the use of
the electric battery. The method of application is as follows : One
pole is gradually approached towards the seat of alleged pain ; the
battery is left in noisy action ; but unknown to the patient the current
is switched off as the pole approaches the alleged painful area. Yet

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the patient frequently complains of very severe pain, describing it as
being like a knife going through him, although in fact there is no
current for him to feel. An ignorant and determined malingerer
assumes, because he hears the battery still in action, that the current
must reach the seat of alleged pain. The value of this test depends
upon it being applied exactly as described, and being repeated two
or three times, so that there may be no possibility of error.

Pain in the back is often not physical but mental. Oh one occasion,
on investigating an alleged tender spot on the back of a woman who
had had a slight accident some time previously, I suggested that if
firm pressure with the palm of the hand was made over the alleged
painful area, and in its neighbourhood, she would not feel it painful ;
she at once agreed to this. Although on very firm pressure in this
way she complained of no pain, yet when I took away my hand and
pressed on the same spot with one finger, she made loud complaint.

Pain is often complained of as radiating in directions in which no
nerves are found. Often a man will complain of severe pain an5rwhere
on his back when this is even lightly touched, but if subsequently
the examiner proceeds to examine his lungs at the back, he will allow
very firm pressure on his back with the stethoscope without
complaining.

The stethoscope may serve more than one purpose in the examina-
tion of a malingerer. Any experiment which results in clear proof
that the examinee is not truthful is alw^ays of value when dealing
with subjective symptoms. On one occasion a man complained of
severe pains, alleged to be due to an accident, in the right side of his
chest, when he took a long breath. I listened with the stethoscope
and asked him to take a long breath, which he said hurt him very
much. But when I removed my stethoscope to the left side of his
chest, and indicated that I had done with the right side, he continued,
when requested, to take long breaths, making no complaint whatever.

Giddiness being a subjective symptom, it is of course practically
impossible dogmatically to deny or affirm the presence of this com-
plaint. After examination, one is often able to say in the witness
box that there is no physical evidence of it, and that one has merely
the man's statement. The following test is useful : the patient is
asked to put his heels and toes together, to touch his toes with his
hands, then suddenly assume an erect position, and then shut his eyes.
If he does this repeatedly and always stands perfectly steady each time,
this is of course not absolutely incompatible with alleged giddiness at
another time, but it certainly goes a long way to prove that he is not
giddy on the occasion of the medical examination.

Traumatic Neurasthenia and Functional Neuroses. — One of the
commonest allegations of injured persons is that they are sufiering
from traumatic neurasthenia. That such a condition exists and is a
very definite disease I am thoroughly persuaded ; but a large number
of cases which are mostly fraudulent, allege traumatic neurasthenia,
as no one who has seen anything of the law courts would dream of

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MALINGERING

denying. Where traumatic neurasthenia ends and fraud begins is not
a territory, but a very thin line. My experience is that highly neurotic
plaintiffs are taught unconsciously to become introspective as the
result of many medical examinations, much interviewing of their
solicitors, many confabulations with friends who have met with the
same or similar injuries, and consciously or unconsciously they feel
pains and aches which, had they taken courage in both hands and
returned to work, would have been either absent or ignored.

On the other hand, there is no doubt that traumatic neurasthenia
frequently occurs, especially in association with an accident of a
somewhat dramatic nature, to which much publicity is given ; a
marked impression is left on the mind, w^hich acts and reacts in a way
detrimental to the injured person’s nervous stability, A large number
of cases of this sort have been very successfully dealt with at my
instigation by the simple process of isolating them from the bad environ-
ment of their sympathetic friends, removing them from consultations
with their legal advisers, and putting them under the care of hospital
physicians well trained in the diagnosis and treatment of functional
nerve disease, combined with firm but kindly niTrsing, abundance of
good food, and suitable occupation. The massage and electric baths
which accompany the above have also a remedial effect, probably also
mental effects. But the main factor in my experience is the isolation
from a vicious environment, and the deliberate attack which is made
upon their morbid mentality.

Malingering in Skin Disease is not very difficult to detect. The
lesion as a rule has an unusual distribution. It is often found in
situations which are easily reached by the right hand, but seldom on
the mouth, nose, ear, scalp, palms of the hands, or soles of the feet.
The marks often run longitudinally (straight lines are unknown in
dermatology?-) ; the ulcers are often perfectly?’ circular. The surround-
ing skin is significantly healthy?^. With regard to alleged sensation,
either the patient complains of excessive pain on light touch, or he
say^s he has no feeling at all. Lesions have a wonderful proclivity
for appearing where they^ are expected, and if in the hearing of such
a patient, a fresh ulcer in a certain place is predicted, the prophecy is
often fulfilled on or about the time mentioned. One of the best
methods of detecting self-inflicted lesions simulating skin disease is
to put on an occlusive dressing of plaster-of-Paris. Much assistance
can often be got from smelling the eruption, and litmus paper often
reveals an acid, which arouses suspicion. In doubtful cases, diagnosis
will often be assisted by the discovery of a pear-shaped mark below
the edge of the ulcer, which is lighter in colour and shows a less intense
inflammation than the primary lesion. The flattened, sliding
epithelium of a large blister in which there are no pemphigus-like
blebs, is suspicious. It is well to remember that all skin lesions,
whether genuine or artiflcial, arc often masked by a secondary
dermatitis, the result of pathogenic organisms aided by scratching.
The character of a lesion depends not only on the means employed to

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produce it, but the method. Some solutions of carbolic acid irritate ;
a pure solution is anaesthetic ; the one will produce a dermatitis and
the other may often lead to gangrene.

Malingering in Hernia. — ^The late Mr. Barnard stated that there was
more attempted fraud from alleged hernia than from any other part
of the body. Most medical men recognize that the origin of hernia
is a congenital patent funicular process, and that the hernia is brought
about by the gradual opening up of this pre-existing closed pouch.
It is perfectly obvious that the peritoneum cannot suddenly stretch
to form a pouch ; anyone who doubts this statement can convince
himself of its truth by making the attempt at the next post-mortem
examination which he conducts. The pressure to produce a hernial
sac must be gradual. The intermittent pressure produced by running,
sneezing, coughing, etc., and the ordinary straining and pulling and
pushing of the working man, sometimes distends the pre-existing sac,
and allow a small portion of the bowel gradually to find its way through.
Occasionally the diagnosis of a recent or old rupture is somewhat
difficult to make, short of actually seeing the tissues, but it is obvious
that a large hernia which reaches to the bottom of the scrotum,
admittedly painless, which can be replaced with the greatest possible
ease, and is accompanied by a large, rounded, thickened inguinal ring,
is a rupture of many years’ standing. It is my practice in difficult
cases to be present, if possible, at the operation for radical cure which
very properly follows the discovery of a rupture, and the brawny hard
mass of omentum, with many swollen veins, and adherent to the sac,
tells its own tale.

Conduct of the Medical Witness in Court, — ^The best preparation for
successful evidence in the law court is a thorough examination of the
patient. When giving evidence never guess. Do not say that a limb
is smaller than its fellow of the other side ; state definitely what
difierence in inches there is in the circumference. Before going to
court always refresh your memory by re-reading your notes taken
from reports given at the time of the examination, and if the subject
is in the least obscure, refer diligently to standard works and
authorities, in order that, if questioned generally on your knowledge
of the subject, your evidence may be both accurate and of value.
Reference to authorities has also this obvious advantage, that isolated
sentences maybe taken from these authorities and quoted against you,
and familiarity with the context is the best preparation for such a
contingency. Quite recently in an important trial 1 was able to point
out to the opposite side that at a former sitting, before I had been
brought into the case, Taylor’s Medical Jurisprudence ” had been
quoted, and a certain statement made, which a later edition (which I
took -with me to court) controverted.

When asked a question, give a definite answer. Expert witnesses
are entitled to give an explanation, but they must first answer the
question. For instance, if asked in a law court : “ Did you prick the
patient with a pin over an alleged painful area ? ” the answer is.

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MEASLES

“ Yes, this was done in the ordinary course of discovering the sensi-
tiveness or otherwise of the alleged painful area.” Never use technical
language. Remember that you are sworn not only to tell the truth,
but the whole truth, which presumably refers to suppressio veri.

Reference. — ' “Malingering.” (Arnold, London.)

MALTA FEVER. Leonard Rogers, M.D,, F.R.C.P.

J. Courmont, P. Savy, and P. MazeP record in detail a case of Malta
fever occurring in the Lyonnais region of France. The pyrexia lasted
eleven months, and was complicated by ulceration of the pharynx,
epistaxis, congestion of the right lung, albuminuria, and hsematuria,
as well as diarrhoea. P. D. Stachan- discusses the frequency of the
occurrence of haemorrhage from the bowel in Malta fever, which,
although very rare, has now been recorded several times.

References. — ^Rev. de Mid. 1912, 99S ; ^S. Afr. Med. Rec. 1912, 364.

MASTOID DISEASE. {See Otitis Media.)

MEASLES. E. W. Goodall, M.D.

D. I. Connolly^ has published the results of 160 cases of measles
treated in the following manner in tjie Manchester Workhouse Hospital :
” As soon as the child is received into the special ward assigned to
measles, a hot bath is given. Then follows a thorough application of
Eucalyptus Oil to the whole body, with the exception of the hands and
the part of the face about the nose, mouth, and eyes. The mouth is
irrigated twice daily with weak Alum Lotion, and Glycerin and Borax
is applied to the interior of the mouth and gums. The throat {tonsils
and fauces) is treated with Carbolic Oil (i-io), morning and evening,
in a similar manner to that described by Dr. Milne. [A firm mop of
cotton-wool on the end of a pair of forceps is thoroughly soaked in the
oil, and with it the tonsils and pharynx are swabbed as far up and
down as possible]. Every day for the following four days the child is
blanket-bathed morning and evening, and again rubbed all over with
eucalyptus oil, the throat and mouth having the same treatment as on
admission.”

The patients were children drawn from the poorest classes of the
community, and were most of them very young, of the ages at which
measles is most common. The results were good ; there were only
8 deaths, a fatality of 5 per cent. The rate in 100 cases during the
previous year was ii per cent. But the complication rate was high,
68 per cent ; in only 18 per cent, however, did the complications
develop after admission. The highest complication rates were those
for the eyes (18 per cent) and the mouth, 13 per cent. [I am inclined
to attribute this success to the very thorough treatment of the mouth
and fauces, which is highly important ; and would hesitate to draw
conclusions as to treatment in measles from so few cases in consecu-
tive years. It is a disease which varies widely in intensity within
narrow limits of time, — E. W. G.]

Reference. — ^Pract. 1912, ii, 664.

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MECKEL’S DIYERTICULUM. (See Intestinal Surgery.)

MEDIASTINAL TUMOURS. J. J, Perkins, M,B,, F.R.C.P.

Lloyd Roberts’- discusses the early signs of mediastinal pressure,
writing from an experience of 36 cases seen during recent years. The
prognosis and results of treatment in this condition are not uniformly
gloomy, as we are apt to think. Of his 36 cases, 22, it is true, suffered
from malignant disease of the lung, glands, or oesophagus, and 2 others
died later from lymphadenoina, but the remaining 12 included examples
of tuberculous glands, mediastinitis, and syphilitic affections. No
fewer than ii recovered more or less completely from their symptoms.
It follows from this that the possibility of syphilis should be borne in
mind, and Antisyphilitic Remedies . vigorously tried, even without a
positive Wassermann reaction. For the tuberculous cases, general
hygienic measures should be adopted and the use of tuberculin
considered.

The paper is largely taken up with a most interesting discussion
on the early diagnosis of mediastinal pressure, which is considered under
the heads of (i) Obstruction to the venous circulation, {2) Obstruction
in the respiratory tract, (3) Referred pains, and (4) Effect upon the
pericardium. Under the heading of venous ohstntction, the dilated veins
seen on the surface of the thorax and abdomen, together with associated
oedema, being familiar to all, the writer calls especial attention to the
symptoms of pressure on one particular vein which is very apt to be
overlooked, the vena azygos major. His attention was first drawn to
the effects of pressure on this vein by a case of general anasarca known
to be due to mediastinal pressure because the heart and urine were
absolutely healthy. The pressure implicated the superior vena cava
and the right auricle, but there was one symptom which hardly fell into
line, namely that the effusion into the peritoneal cavity was quite
insignificant in comparison with the oedema of the abdominal wall and
lumbar region. These parts being drained into the azygos vein
suggested that pressure on its course might be the cause of the peculi-
arity, The post-mortem examination showed that this was the case,
and the writer was able to verify the value of the symptom in subsequent
cases. Occasionally the oedema met with in obstruction of the vena
cava may be quite brawny, with almost complete absence of pitting.
Some brilliant examples of the complete disappearance of this condition
under specific treatment are given.

Under the heading of respiratory pressure, attention is called to the
association of three physical signs as almost distinctive, viz., normal
resonance, diminished or absent breath sounds, diminished or absent
tactile fremitus. Such cases, of course, are often mistaken, as the
writer points out, for phthisis or pleural effusion, an error -which would
be avoided by a careful attention to this triad of physical signs. Among
the other symptoms, he calls attention to the inequality of the pupils
often present ; and to the various forms of pain, which may for a long
lime have been the chief if not the only complaint, and which should

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MENSTRUAL DISORDERS

lead to careful examination of the chest. The writer considers peri-
carditis as almost diagnostic of malignant growth in the aged, as it is
of rheumatism in the young or of Bright’s disease in middle life. The
importance of examining for enlarged supraclavicular glands is
emphasized ; the diagnosis, once suspected, can be confirmed in most
instances by jv-ray examination.

Reference. — '^Lancet 1912, ii, 1714.

MELiENA NEONATORUM. {See Hemorrhages in the Newly -Born.)

MENINGITIS, OTITIC. [See Otitis Media.)

MENINGITIS, TUBERCULOUS. Purves Stewart, M.D,, F.R.C.P.

In a series of forty-one cases of tuberculous meningitis (of which
thirty-eight were verified by autopsy, and the three remaining cases
had tubercle bacilli in the cerebrospinal fluid), Garrod and Frew^ found
glycosuria to be present in no less than fifteen, i.e., nearly 37 per cent.
In every case daily examinations of the urine were made from the date
when the diagnosis of tuberculous meningitis was first established.
Glycosuria was found to be a terminal symptom, occurring as a rule
during the last two days of life. Only in one case did it appear four
days, and in one other case three days, before death. Once estab-
lished, it persisted for the remaining days of the patient’s life. Other
forms of meningitis (post-basal, meningococcal, pneumococcal, influen-
zal, etc.) showed no glycosuria, even though the clinical symptoms
were as severe as in the tuberculous cases. The cause of the glycosuria
is at present obscure.

Reference. — "^ Lancet , 1913, i, 15.

MENSTRUAL DISORDERS.

Victor Bomiey, MS., M.D., BSc., F.R.CS.

Bryden Glendining, M.S., F.R.CS.

Artificial Menopause. — Ovarian Grafting. — Davidson^ describes
three cases in each of which thin slices of the patient’s ovary were
grafted into the rectus muscle. He chose _.this site for two reasons ;
if anything went wrong, it would be easy to get at the grafts without
opening the abdominal cavity, while if the graft took, swelling and
tenderness at the period could be easily identified. In one case it did
not take, and the menopause followed the operation. In two cases it
took ; the patients had periodic discharges of blood from the uterus,
and the graft became swollen and tender. Davidson claims that his
patients, who suflered from severe pelvic pain before operation,'
completely lost it afterwards.

Whitehouse^ describes a case of ovarian grafting. He cut the
healthy ovarian tissue into small pieces and scattered them in the
subperitoneal connective tissue and in the rectus muscle. Menstruation
came on after the operation, and has continued ; there are no symptoms
of the menopause, and no pain in the abdominal wall when the period
occurs. He considers that minute grafts in a very vascular bed (muscle

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is satisfactory for the purpose) give the best results ; and that the
ovarian tissue should be left in the body fluids within the peritoneal
cavity until it is ready for grafts. Absolute asepsis and avoidance
of strong antiseptics, which would damage the tissues, are very
important.

Hill® writes a note on the use of Desiccated Corpora Lutea, stating
that he has seen consistently good results following its administration
for the symptoms of artificial menopause. An enquiry into the cases
of failure shows that the duration of the treatment was too short. He
gives 5 gr. three times a day, half an hour before meals ; the treatment
is continued for at least one month, and often for two, amounting to
100 to 200 capsules.

Dysmenorrhosal Membranes , — ^Blair Bell^ believes that there are only
two forms of uterine casts passed during menstruation, blood casts and
endometrial casts. The former are merely retained clots formed of
menstrual blood, which normally does not coagulate. The clotting he
considers is due to an unhealthy condition of the endometrium, or to
very rapid flow of blood. The passage of these clots gives rise to
, dysmenorrhoea. Endometrial casts are not common, and when thick
are very difficult to distinguish from abortions. Sections show a
deciduahlike change in the stroma cells of the endometrium. Though
many people think these casts are early abortions, the specimens
described by Blair Bell w’ere obtained from a woman who two years
previously had had both tubes and ovaries removed.

References. — ^Edin, Med. Jour. 1912, ii> 441 ; ^Clin. Jour. 1913/ May,
.107; ^Surg. Gyn. and Obst. 1913, i, 712; ^Ibid. 651.

MENTAL DISEASES. Bedjord Pierce, M.D., F.R.C.P.

Etiology. — The problems which surround the etiology of mental
disorder continue to be attacked from several standpoints. Two
schools of thought flourish. They were forcibly illustrated by the
proceedings of the International Congress of Medicine on two
successive days. One w'as devoted to the consideration of the toxic
insanities, the next to psycho-analysis. At the former a distinguished
author enunciated the dictum, “ All insanity is either toxic or trau-
matic,” and there was no reason to think he included under the latter
term what is frequently spoken of as psychical trauma. According to
this school, the content of the mental disturbance is of small account,
and little importance is attached to psychical factors of causation,
such as the effect of mental stress, or of shock or terror, except in so
far as these may produce alterations in, the bodily secretions or
disturb metabolism. The other school of thought is chiefly concerned
with the past mental history, the internal conflicts and struggles, the
previous experiences, the eflect of repression and restraint ; and in
these they find not only an explanation of the symptoms present, but
also a means of cure. This brief description is probably just to
neither party, but it will suffice to indicate the differences of~ opinion
that arise when etiological problems are considered.

NEW TREATMENT

MENTAL DISEASES

In controversies of this kind it is not unusual to find that both
parties are not far from the truth, and though at the present time
no dogmatic statements can be made, it will be safe to say that insanity
usually arises from the interplay of three factors : heredity, toxaemia,
and mental stress. These rarely, if ever, act singly. We can hardly
conceive of a toxic agent creating ideas, as the latter must depend
upon the individuahs previous experiences ; on the other hand, the
person's reaction to external influences depends largely upon inherited
predisposition and on the state of his bodily health.

There is a steady growth of opinion that by psycho-analysis
and other methods of psychical investigation it is possible to
trace the development of morbid ideas and impulses. At the
same time it is recognized that these mental symptoms may never
have appeared but for the influence of some toxic agent acting on
the nervous system.

The question of causation is discussed by Chambers^ in his
presidential address “ On the Prevention of the Insanities," to the
Medico-Psychological Association. He quotes Murri with approval :
" Causation consists in the result of several individual factors
co-operating in the production of one and the same effect." He
proceeds : ‘ ‘ But the complex of causative agencies which we have to
recognize in the case of the insanities is one wliich, if the phrase be
allowed, has extension in two dimensions. In the delirium of typhus
fever the physical agencies are in formidable rank, but in certain
insane conditions, which are hardly to be distinguished clinically from
such delirium, we have to do battle with an enemy whose Indian file
issues in dim perspective from the gloomy recesses of an unknown
past. . . . Possibly with the advance of knowledge we may find that
there will become more clearly discernible than at present some line
of demarcation between the insanities that disappear when physical
states are rectified, and those whose causation now appears to be
more complex. ... A new importance has been given to the unwind-
ing of the causal claim, by the recognition of the unconscious memories
of bygone days as determining forces in the psychoses of maturity.

. . . Long ago, Oliver Wendell Holmes, in speaking of the ‘ rosy
pudency of sensitive children,' taught us that ‘ the first instinctive
movement of the little creatures is to make a cache and bury in it
beliefs, doubts, dreams, hopes, and terrors !’...' Everybody has
had his childish fancies, but sometimes they are passionate impulses
which anticipate all the tremulous emotions of a later period." In
this connection he asks if the etiological relationship between some
states of body and mind, as we see them, have ever been more neatly
expressed than by the dreamer amongst the water-lilies of the Ouse
when he wrote : —

* Faults in the life breed errors in the brain ;

And thsse reciprocally, those again.' ”

Reference. — '^Jouv. Ment. Sci. 1913, Oct.

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MESENTERY, SWELLINGS ARISING IN.

Sir Berkeley Moynihan, M.5., F.R.C,S,
Harold UpcoU, FH.CS.

Poulsen^ reports a case of chylous cysts of the mesentery in a girl
of seven who had suffered for six months from brief attacks of intestinal
obstruction. Finally, there occurred an attack which was not relieved,
as the previous ones had been, by aperients. Diagnosing appendicitis,
the abdomen was opened, revealing multiple cysts in the mesentery,
complicated by volvulus of a loop of small intestine, with perforation.
Resection, with entero-anastomosis, was followed by recovery. Exam-
ination of the specimen showed three large and numerous small chylous
cysts. Two of the larger cysts lay between the muscular and serous
coats of the intestines (an unusual situation), while the remainder lay
between the leaves of the mesentery.

Floderus^ has collected 75 cases oi primary tuberculosis of mesenteric
glands from the literature, and reports 18 personal cases. Infection
usually occurs from the intestinal tract, and it has been shown that
the bacilli may infect the glands after passing through the intestinal
wall without leaving any trace of its passage. The disease most
frequently occurs in the first two decades of life. Among the initial
symptoms, are abdominal pain, malaise, anorexia, loss of strength, and
emaciation. The pain is usually localized in the umbilical or csecal
region ; if severe, it may indicate the onset of obstruction or peri-
tonitis, especially if accompanied by vomiting. Sometimes the
presence, of a palpable tumour will aid in the diagnosis, and the presence
of calcified glands may sometimes be demonstrated with the A'-rays.
The principal complications are tuberculous peritonitis from rupture
of a suppurating gland, and obstruction, either from pressure of the
tumour mass or from adhesion of intestine to the inflamed glands.

Treatment is at first medical. All possible sources of further
infection should be eliminated from the food, and the patient should
be placed in the best hygienic surroundings. If these measures fail,
operation may be resorted to. Simple exploratory laparotomy is said
to give as good results as in tuberculous peritonitis, but the number of
reported cases is too meagre to draw any definite conclusions. Enucle-
ation of the enlarged glands is usuallyipractised, and the results are
good even when the removal is incomplete ; Floderus has treated the
glands thus in five cases, and resected a segment of intestine, without
any mortality.

References. — Kirch, f. klin. Chir. 1913 , 139 ; ^Surg. Gyn. and Obst.
{ahsir.), 1913 i, 24.

MUMPS. E. W. Goodalh M.D.

Felling,^ from a study of forty consecutive cases, found that the
blood in mumps shows definite changes in the corpuscular content,
a slight increase in the total number of leucocytes, and a lymphocytosis
which is both relative and absolute. This lymphocytosis is present
on the first day of the disease, and persists for at least fourteen
days. The occurrence of orchitis does not invariably alter the blood

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MYOSITIS

picture, which is of distinct diagnostic value in diJfferentiating mumps
from other inflammatory swellings of the parotid or submaxillary
salivary glands, and from cases of lymphadenitis.

He also records the results of the examination of the cerebrospinal
fluid in a case of mumps followed by symptoms of acute meningitis,
and refers to other published cases of a like nature. He concludes
that a lymphocytosis of the cerebrospinal fluid occurs in mumps, when
that disease is complicated by meningitis or by lesions affecting the
cranial nerves ; and that it has also been found in cases of mumps
which have presented no clear clinical symptoms of any organic lesion
of the nervous system. He thinks that the virus of mumps excites an
inflammatory reaction in the body whose characteristic feature is a
great aggregation of lymphocytes.

Two cases of acute enlargement of the ovary, seemingly due to inflam-
mation, immediately following an attack of mumps, have been recorded
by Harlow Brooks. ^ Both patients were j^oung adults ; in one the
mammae were also affected, and appeared to undergo atrophy. This
complication of mumps is rare ; at any rate very few cases have been
recorded.

References. — '^ Lancet , 1913, ii, 71 ; ^Jour. Amer. Med. Assoc. 1913, i 359.

MYCETOMA. Leonard Rogers, M.D., F.R.C.P.

R. L. Sutton^ reports on the occurrence of mycetoma in America,
and records two cases in detail. He agrees with other recent workers
in regarding the parasite as a streptothrix. The only treatment is
Amputation. In one patient who refused operation, only slight
improvement resulted from Potassium Iodide and Copper Sulphate
(o‘02 mgram) internally and Iodine locally.

Reference. — ^Jour. Amer, Med. Assoc. 1913, ii, 1339.

MYCOSIS FUNGOIDES. E. Graham Little, M.D., F.R.C.P.

Howard Fox^ reports a well authenticated case of psoriasis of twenty-
five years standing, succeeded by the development of equally well-
authenticated mycosis fungoides, without the prodromal stage in
which intense itching is so common a feature. These premycotic
eruptions have often been mistaken for psoriasis, but instances in
which the actual diagnosis of that disease has been made by experienced
dermatologists are very uncommon ; the author can only find two such
besides his own. [See also Skin, General Therapeutics of.]

Reference. — ^Jour. Amer, Med. Assoc. 1913, ii, 330.

MYOSITIS, ISCHEMIC. Purves Stewart, M.D., F.R.C.P.

This variety of deformity is much commoner than the somewhat
scanty references to it in the ordinary text-books would lead us to
suppose. ' Originally described by v. Volkmann more than twenty
years ago, it is a syndrome confined almost exclusively to the upper
extremity. It occurs chiefly in children and adolescents, and is due,
in every case, to constriction of the limb by a splint or bandage which
has been too tightly applied. An incomplete ischaemia is thereby

wyosiTis

3/0

MEDICAL ANNUAL

produced (complete ischaemia would cause gangrene), and the subjacent
muscles undergo coagulation of their contractile substance. This is
followed by acute myositis and, finally, by fibrous transformation of
the muscles, with permanent shortening and deformity. The muscles
affected are those on the ffexor aspect of the forearm ; the extensor
group remains unaffected. The fibrous sclerosis of the affected muscles
is patchy and irregular, varying in degree in different cases. Thus
above and below the bands of sclerosis there may be areas of normal
muscle-fibres (see Fig. 40) giving to the muscles, as pointed out by
Binet,^ a digastric or tiigastric character.

This muscular affection comes on rapidly,
in the course of a few days, following the
application of the splint or bandage.

The premonitory^ symptoms supervene
within a few hours, and it is important to
recognize them, since by promptly relieving
the constriction, the serious and permanent
signs of the full^’-developed syndrome can
be avoided. These premonitory symptoms
consist of pain in the hmb (sometimes
absent), swelling of the hand, and cyanosis
of the fingers.

Once the malady is established, its signs
are permanent. There is a special deformity
of the hand, which, owing to shortening of
the flexor muscles, is flexed at the wrist and
at the interphalangeal joints, whilst the
metacarpo-phalaiigeal joints remain ex-
tended. This flexion of the fingers varies
in intensity in different cases, and may
attain to an extreme degree. Not infre-
quently^ the thumb escapes (having its ovm
long flexor), whilst the four other digits are
severely affected. If the wrist be passively
flexed still further, the flexor muscles are
slackened, and the fingers can then be slightly extended. On the
other hand, attempted extension of the wTist exaggerates the deformity
of the fingers. The patient himself is unable to extend the fingers
voluntarily. The electrical reactions in the surviving fibres of the
contracted muscles remain nonnal.

Treatment. — Once the affection is established, passive stretching
of the muscles is valueless, as also are massage or other manipulations.
The only satisfactoiy^ remedy is to lengthen the flexor tendons by a
somewhat difficult plastic operation, or, more simply, to excise a portion
from the shafts of the radius and ulna, enough to allow of the fingers
being placed in a position of extension or e\’en of slight hyper-extension.
The patient then has a shortened forearm, but it ends in a useful hand.

Reference. — La Presse Mid, 1912. 712.

Ff£ 40. — Musdes of the palmar
aspect of the fore-arm affected
by ischsemic contraction . (After
La Pivsse Medkale.)

NEW TREATMENT 371 NASAL ACCESSORY SINUSES

NASAL ACCESSORY SINUSES. W. G. Poriey, M.B., FM.CS.

For the treatment of chronic suppurative ethmoiditis, Hajek^
advocates Intrauasal Operation under good local anaesthesia (cocaine
with adrenalin) and the removal of as much as possible at one sitting,
a sine gucl non being absolute orientation during the whole operation.
If necessary, local obstacles, such as a deviated septum, must previously
be corrected. Repeated sittings may be necessary before the whole
of the disease is removed, but sufficient time must be allowed between
them to allow all reaction to pass off. Packing should be avoided
if possible, during the after-treatment. Extranasal Operation is
indicated when the intranasal method has proved insufficient, when
the frontal sinus is markedly affected and requires operation, or when
orbital abscess is present or threatened. Lambert Lack, in *con tinning
the discussion, deprecated the piecemeal operation, and advocated
his intranasal operation, which is carried out in one sitting, under
general anaesthesia, guided by the sense of touch. He has had one
death in 300 cases, and knows of six deaths and two cases of blindness
under other operators. [This is a some%vhat formidable list of fatalities
when it is remembered that the slower methods, or, failing them, an
external operation, are not attended with risk to life. — ^W. G. P.] He
limits the operation to patients under 50 years of age ; and when
there is frontal sinus suppuration or orbital complication, he prefers
an external operation.

Double Sphenoidal Sinus Stippumiion . — Watson Williams® recom-
mends the removal of the posterior half inch of the upper part of the
bony septum nasi corresponding with the sphenoidal sinus septum.
This gives a very free opening into the sinuses, and does not tend to
close, as is frequently the case when the anterior wall alone is removed.

Dan McKenzie® gives a systematic account of diffuse osteomyelitis
from nasal sinus suppuration^ the association of which with sinusitis
was first detected by Tilley. His remarks are based upon the records
of 48 cases. Diffuse osteomyelitis of the cranial bones may be compared
with chronic diffuse osteomyelitis of the long bones, but differs in that
it is referable in the vast majority of cases to some continuous infective
focus. Of the 48 cases, 45 originated in the frontal sinus and 3 in the
antrum. There is an absence of records of osteomyelitis arising from
the sphenoidal sinuses or ethmoidal labyrinth. There is therefore no
doubt that frontal sinus suppuration leads more frequently to this
condition than maxillary disease.

As regards the process of infection, nothing is known definitely:
whether it takes place by direct invasion of the bone spaces or by the
efferent veins : the author inclines to the former view. Some other
factor must, however, also be present, or osteomyelitis would be much
more frequent; and possibly, as Shilling suggests, it is because the
diploe as a rule abuts upon the walls of the sinus at one place only,
namely, at the upper recess. McKenzie, however, believes too much
stress should not be laid on the anatomic structure of the bone. Once
the bone is affected, the condition tends to spread without limit, and

NASAL ACCESSORY SINUSES

372

MEDICAL ANNUAL

may involve the whole cranial vault ; this is generally attributed to
thrombophlebitis of the diploic veins. The affection of the bone is
a purulent rarefying osteitis leading to destruction of all its constituent
elements. The pus which originates in the diploe at a later stage forms
abscesses between the bone and pericranium and the bone and dura.
At a still further stage, areas of bone become necrosed and are exfoliated
as sequestra. In favourable cases the gaps are filled up later by the
formation of new bone. Metastases to distant parts of the body are
rather rare, and were recorded in only 5 cases. Of local extensions,
leptomeningitis occurred in 15 cases, brain-abscess in 10, thrombo-
phlebitis (intracranial) in 9, and subdural abscess in 3.

As regards age incidence, the spontaneous cases preponderate in the
second and the post-operative in the third decade of life. Cases of
osteomyelitis may be di\dded info spontaneous and post-operative.
Out of 41 of the author’s collection, 20 belonged to the former and
21 to the latter category. In regard to the latter, in several instances
the disease did not appear until some weeks after operation. Of the
spontaneous cases, 7 recovered after appropriate treatment, while not
one of the post-operative recovered. What factor in the operation
it is that leads to osteomyelitis is not known, though possibly curetting
the walls of the sinus, inadequate drainage, and injudicious bruising
of the bone edges by forceps will predispose to its occurrence. The
exciting cause in spontaneous osteomyelitis is equally unknowm,
though the disease is more common in acute than in chronic sinusitis.

The author divides these cases into the acute, lasting three to tw^elve
weeks ; and the chronic, with a duration of six months to two years.
In the former, pyrexia is continuous and the progress of the disease
uninterrupted. In the chronic t}q)e the progress of the disease is
broken, and in the periods of intermission may appear cured. In
spontaneous osteomyelitis the disease may be unsuspected until the
sinus is opened ; but the appearance of an oedematous swelling at some
distance from the sinus is suspicious, and there is usually a rise of
temperature above its previous readings. In post-operative cases the
onset is even more insidious ; the wound may have healed and the
temperature be normal, when a superficial swelling appears which slowly
extends and does not improve on being opened, and the discharge of
pus becomes plentiful. Pyrexia, headache, and symptoms of toxaemia
appear, and sooner or later an oedematous swelling of the soft parts
develops beyond the confines of the sinus. The opening of abscesses
as they form, and the removal of necrosed bone, cause temporary
checks to the disease, but recurrence takes place, and nearly always
death finally results from toxaemia, p^’^mia, asthenia, or some intra-
cranial complication.

Diagnosis. — This rests on the appearance of an oedematous swelling
of the bone beyond the affected sinus, but syphilitic disease of the
frontal bone may be mistaken for osteomyelitis.

The author points out that the recognition of the risk of post-
operative osteomyelitis has completely revised the indications for

NEW TREATMENT

373

NEPHRITIS

operation on the frontal sinus, which nowadays is rarely undertaken
solely because there is a purulent discharge from the cavity. If
operation is performed, many writers postpone suture of the external
wound, and further curetting of the cavity should be avoided. Once
osteomyelitis has set in, the only chance of saving the patient lies in
the immediate and entire removal of the diseased bone. If recovery
takes place, the defect will be made good by osseous regeneration.

References. — Med. Jour. 1912, ii, 1130; ^Jour. of Laryngol. 1912,
591 ; ^Ibid. 1913, 6, 79, and 129.

NECK, CYSTIC HYGROMA OF. Priestley Leech, M.D., F.R.C.S.

Dowd^ reports three cases, and probably four, of cystic hygroma ;
he gives a summary of the other recorded examples, 91 located in the
neck, and 35 situated principally in the axilla, but in part at least
extending thither from the neck. The term should be restricted to cysts
lined with endothelium, and having a marked power of growth. The
most satisfactory explanation of their existence is that embryonic
sequestrations of lymphatic tissue existed, and that they had the
power of persistent irregular growth.

Excision is the best treatment ; if this is impracticable, partial
removal is the next best.

Reference. — '^Ann. Surg. 1913, i, 112.

NEPHRITIS. Francis D, Boyd, M,D,

High Arterial Tension. — [See also Blood-pressure.) — Janeway^
reviews in detail our present knowledge of the problems of nephritic
h5rpertension from both clinical and experimental standpoints.

In nephritis, the cause of the high blood-pressure and that of the
cardiac hypertrophy must not be identified absolutely, though, in the
main, the hypertrophied heart may be looked upon as the result of
persistent high blood-pressure. The purely mechanical theory, which
ascribes the high blood-pressure to increased resistance in the kidney,
must be abandoned, A theory which is partly mechanical is based on
the claim that anatomical study shows a parallelism between the extent
of the glomerular changes and the hypertension. Such a hypertension
might be considered as compensator^^ and of the nature of a regulatory
mechanism to ensure sufficient circulation through a kidney showing
extensive capillary obliteration. This theory, however, cannot be
accepted on anatomical grounds, as cases wdiere marked cardiac hyper-
trophy exists may show little glomerular change ; and amyloid disease,
which is par excellence a disease of the glomeruli in its pure form, seldom
if ever increases blood-pressure or causes hypertrophy.

Much experimental work has been done on dogs by reducing the
amount of functionating kidney, and observing the effect on urinary
secretion and blood-pressure. In reviewing the subject, Passler con-
cludes : (i) That the hypertrophied heart in nephritis is the result of
kidney disease ; (2) That as a result of the renal lesion there probably
occurs an increased irritability of the vasoconstrictor apparatus, result-
ing in arterial spasm and an increased resistance in the systemic

NEPHRITIS

374

MEDICAL ANNUAL

circulation, with hypertrophy of the left ventricle ; (3) That the hyper-
trophy of the left auricle and the right heart in nephritis, is a later con-
sequence of insufificiency of the left ventricle. This he argues, not only
from the finding of pure left ventricular hypertrophy in his experi-
ments, but from a critical review of the clinical evidence, Janeway
carried out a number of experiments which confirmed the views of
Passler.

Many attempts have been made to discover chemical substances
exerting, a pressor effect. Renin may be dismissed both on clinical
and experimental grounds. The development of the “ adrenalinaemia
theory of hypertension is a fascinating chapter in the history of specu-
lative medicine. Suprarenal lesions have been described by many
observers, but it seems probable that the changes found in the gland
are the result of local arteriosclerosis of its own vessels rather than vice
versa. The experimental lesions produced by epinepJirin are quite
unlike human arteriosclerosis. Janeway and Park, as the result of a
long series of experiments made b}- a modified INIeyer method, concluded
that the vasoconstrictor substance of defibrinated blood is not epine-
phrin, and that the substance acted on the smooth muscle directly,
without relation to its synnpathetic innervation. Neither with normal
blood nor with the blood of hypertensive patients could any definite
trace of epinephrin effect be obtained. The problem has been ap-
proached by the investigation of blood-sugar. It is well known that
the injection of epinephrin into an animal whose liver contains glycogen,
results in an increase of sugar in the blood which, if it reaches a suffi-
ciently high percentage, induces transient glyxosuria. It has there-
fore been reasoned that if hypertension is associated with increased
circulating epinephrin, hyperglycaemia should be present. The results
obtained so far have been conflicting. Janeway ’s observations are
highly suggestive of the presence of epinephrin in the blood of a patient
with high pressure and hyperglycaemia, but are too variable to permit
the conclusion that the substance has been identified. Experimental
medicine has not then solved the riddle of hypertension, nor can
clinical medicine make the claim.

Janeway gives an analysis of the histories of 459 private patients
whose blood-pressures registered over 165 mm. Hg. The patients
fall into two groups, as made up of individuals well past middle life.
The clinical picture is usually that of some degree of cardiac insuffi-
ciency, and their death is cardiac. Arteriosclerosis is a commonly
associated lesion ; anginoid attacks are fairly frequent. About 10
per cent are elderly diabetics. \Miile the bulk of them at some period
show albumin, casts, and other urinary changes usually interpreted as
indicating nephritis, and while at autopsy the majority prove to have
either arteriosclerotic atrophy of the kidney or the so-called “ primary
contracted kidneys” it must be borne in mind that during life many of
these individuals fail to show any urinary^ change other than those of
chronic passive congestion. There are also a number of autopsy? cases
in which the clinical picture of permanent high blood-pressure has been

NEW TREATMENT 375 NEPHRITIS

associated with kidneys found to be normal or with mere secondary
congestion due to failing heart. In the main, the treatment of these
individuals lies in safeguarding the heart. From the clinical stand-
point they may be described as cases of hypertensive cardiovascular
disease. A closely related group shows predominant cerebral symptoms
— headache, vertigo, apoplectic attacks. Polyuria is found more
frequently in this group, and there are evidences of severe functional
damage to the kidneys. We should recognize clearly that the differen-
tiation of the various anatomical types of nephritis is altogether beyond
the powers of clinical diagnosis. The clinician is concerned with
structural changes only so far as they give rise to disturbances of
function, and can be utilized for diagnosis or prognosis. ^Vhen hyper-
tensive cardiovascular disease exists, and investigation of the kidney
function shows no change of importance, it is immaterial what may be
the exact appearance of the kidney ; the patient must be treated from
the standpoint of the circulatory disorder. Pathologists are returning
to the fundamental idea that the real disease at the back of what we
call chronic interstitial nephritis, is a disease of the small blood-vessels,
and that the lesion of the kidneys is a secondary manifestation. Hyper-
tensive cardiovascular disease is recognized clinically as a widespread
disease of the arterioles in the various internal organs. The disease
in its fully developed form involves the kidney, producing the small
red granular or primary contracted kidney ; but occasionally leaves
it- untouched.

Arteriosclerosis of the larger vessels may spread peripherally, but it
constantly leads to high blood-pressure and hypertrophied heart.
Patchy arteriosclerotic atrophy of the kidney is present, rather than the
more diffused changes of arteriolar disease. Clinically, it is more
commonly connected with insuihciency of the heart.

The symptoms of hypertensive renal disease may arise in three ways :
(i) From purely quantitative reduction of kidney substance below the
factors of safet\^ ; (2) In connection wdth the unknown intoxication
which causes disturbances of the central nervous system, and which
we call uraemia ; or (3) In primary irritability of the vasoconstricting
mechanism from unknown, probably extrarenal, causes, which lead
eventually to arteriosclerosis. In the latter type, the disease of the
kidney is the sequel, not the cause, of the generalized vascular lesion.
No one can yet say whsd are the vascular poisons responsible for these
types of hypertensive disease. Epinephrin may be one of them — that
it is the only one seems improbable ; the same applies to the secretion
of the hypophysis. The first and second types of hypertension may,
at any time, be superimposed upon the third ; while the second, the
uraemic type, must be considered dangerous in itself. Hypertension
in the arteriosclerotic kidne^?^ is best regarded as a compensatory effort
of the organism, to be interfered with only when danger threatens
either through cardiac failure or through cerebral haemorrhage.

Protein-free Diet. — ^The elimination of end-products of protein meta-
bolism constitutes a large proportion of the total work the kidney has

MEPHRITiS

37 ^

MEDICAL ANNUAL

to perfoniL If the kidney power is insufficient, waste materials accumu-
late in the blood ; the kidne3'' is stimulated to further efforts, and its
decreasing power is shown b}’ gradual increase in the quantity of urine,
a fall of specific gravity, and a rise in the blood-pressure. GoodalP
points out that it is sought to save the kidney by diminishing the intak-
ing of nitrogenous foods ; but in practice it is thought unsafe to restrict
protein intake below 50 to 60 grams, a quantity sufficient to keep up
nitrogenous balance. There is evidence, however, that the sudden
withdrawal of protein from the food causes no particular disturbance.
Health^^ individuals can be kept on a starch and cream diet, yielding
only about i gram of urinary nitrogen and 3000 C. of energy, for periods
of seven to ten days, without injurious effects.

Goodall relates an experience of the use of periods of low protein diet
in six- cases of chronic interstitial nephritis which were all in a fairly
advanced stage, showing cardiovascular changes. In one case, a
starch and cream diet was used, but owing to its monotony was aban-
doned ; and a diet instituted consisting of sweets, such as candy, honey,
sugar, marmalade ; fruits, as apricots, apples, bananas, blackberries,
grapes, lemons, melons, oranges, peaches, pears, prunes, raspberries,
strawberries ; vegetables, such as asparagus, beans, oats, cabbage,
carrot, cauliflower, celery, cucumber, lettuce, onions, potatoes, rhubarb,
turnips, spinach, tomatoes, Brussels sprouts, rice ; starches, such as
tapioca, arrowroot ; fats, as butter, olive oil, cream ; relishes, as olives,
vinegar, lemon juice, cucumber, and pickles. No difficulty was expe-
rienced in maintaining the caloric requirements of the body. With
these foods the quantity of nitrogen excreted in the urine is the same
as with the starch-cream diet. At the end of a period of five days,
amounts of protein not exceeding 60 grams, were added. These addi-
tions were made on the basis that 60 grams protein are contained in
eight ounces of fresh beef, twelve ounces of fresh fish, two quarts of
milk, nine eggs, twenty-one ounces of bread, and thirteen ounces of
oatmeal (uncooked). Charts of the observ^ations are given, showing
the blood -pressure, amount of urine, and urinary nitrogen excreted.
In every case, relief of symptoms followed the nitrogen-free period.
In every case there was a distinct fall in the blood-pressure. In every
case but one, the sudden fall in blood-pressure was followed by a
temporary rise on the fifth or sixth dscy. In all but one, the quantity
of urine fell to normal. In aU but one, the area of cardiac dullness
decreased. It is obvious, then, that a protein-free diet can be main-
tained for a period of five to ten days without harm to the individual.
With such a restriction, the accumulated end-products in the blood
are promptly eliminated. The nitrogen contained in the blood falls
to normal, and the kidneys and heart are given an opportunit}" to rest.
Such a restriction may be followed by a low-protein diet for a consider-
able period of time, even in advanced cases, without return of the dis-
agreeable symptoms. The protein-free diet may be employed at inter-
vals of not less than six or eight weeks.

References. — '^Amer. Jour. Med. Sci. 1913. i, 625 ; -Bost. Med. and Surg.
Jour. 1913, i, 760.

NEW TREATMENT

377

NEURALGIA

NEURALGIA, TRIGEMINAL. Piiwes Stewart, M,D., F.R.C,P,

The treatment of trigeminal neuralgia by means of Alcoholic Injections
into the foramina of exit of the branches of the nerve from the skull
has now become securely established in practice. In the Medical
Annual of 1909 and 1910 I described the technique of injections into
the sphenoidal fissure, the foramen rotundum, and the foramen ovale.
Those of us who have practised deep alcohol injections, have now and
then observed cases in which the alcohol reached not merely the nerve-
trunk at its exit from the skull, but also the Gasserian ganglion itself,
as evidenced by complete anaesthesia of the whole trigeminal distribu-
tion, and even by the occurrence of herpes near the angle of the mouth,
as in several cases of my own. When the ganglion with its nerve-cells
is thus attacked, the effects of the alcohol injection are much more
likely to be permanent than when we only destroy the infraganglionic
nerve-fibres, which, in the
course of time, tend to re-
generate, and to conduct
painful impulses once more.

The ideal injection, therefore,
is one which directly aims at
injecting the Gasserian itself.

In this connection a valu-
able paper by HarteT has
been published, wherein he
discusses in detail the anato-
mical relations of the Gasse-
rian ganglion, and describes a
new method of reaching it
through the foramen ovale
{Fig. 41). Hitherto the usual
path of approach to the fora-
men ovale has been trans- 41-— Hilrtel’s method of reaching the Gasserian

, , , . . ganglion, showing needle piercing the foramen ovale in

versely, along a line running the direction of the long axis of the latter.

between 2 J and 3 cm. in front

of the osseous external auditory meatus, below the arch of the zygoma,
the needle reaching the foramen ovale at a depth of about 4 cm.
from the surface.

Hartel approaches the Gasserian ganglion along the long axis of the
foramen ovale itself, i.e., from the front of the face, since the direction
of the foramen is forw^ards, downwards, and outwards. It is important
to enter the needle tlirough the skin of the cheek without puncturing
the buccal mucosa. In this way we avoid septic infection from the
mouth. The foramen ovale varies in shape and size within certain
limits, so that individual peculiarities have always to be reckoned with.
It is a canal about i cm. long, rather than a foramen ; and opens below
on a smooth bony surface, along which the injection needle must
approach. Posteriorly and internally from the orifice of the foramen
ovale the bone is rough, irregular, and covered with cartilage and

NEURALGIA 378 MEDICAL ANNUAL

fibrous tissue. If, therefore, the point of the needle impinges on
tissues of this sort, we know* at once that its direction is wong, and it
must be withdrawn to an anterior and external plane. In approaching
the foramen from before backwards, the needle must keep close to the
outer side of the external pterygoid plate, care being taken never to
get away from its hard smooth surface. The needle-point then follows
a curve convex outwards.

A successful puncture, reaching into the Gasserian ganglion, must
avoid injuring certain important structures, such as the cavernous
sinus, the internal carotid artery, the superior petrosal sinus, and the
brain itself. Fortunately, if the needle be accurately in the long axis
of the foramen ovale canal, it usually avoids these structures, provided
that the point is not pushed upwards for a distance further than 14 mm.
from the under surface of the temporal bone. Owing to slight varia-
tions in the direction along -which the canal of foramen ovale runs
downwards, the anterior end of the injection needle, i.e., the point of
entrance close to the upper jaw, varies also. The average point of
entry, according to Hartel, is the upper alveolar border of the second
upper molar tooth. This he found to be accurate in 90 per cent of
skulls. If w^e fail at this point, another spot is selected along the
alveolar margin of the upper jaw, slightly behind or in front, all the
punctures converging towards the lower opening of the foramen.

The technique, then, is as follows : The alveolar border of the second
upper molar is identified, and the skin of the cheek pierced opposite
this point. A finger within the mouth feels the needle through the
mucous membrane (which must not be punctured), and guides it along
the outer border of the upper jaw between the low'er jaw (with masseter
and temporal muscles) on the outer side, and the maxillary tubercle
on the inner side, traversing the substance of the external pterygoid
muscle. The depth of the foramen from the starting-point at the
second molar tooth is usually from 5 to 6 cm. This is conveniently
marked by means of a small movable metal indicator shding upon the
needle, whose distance from the point is accurately measured before
starting. This indicator can be felt in the substance of the cheek.
The direction is further verified by pointing the needle (looking from
the front) towards the pupil of the corresponding eye. It is convenient
to check this by means of a second needle laid along the outside of the
cheek. Looking at the face from the side, the needle-point should be
directed toward the articular tubercle of the zygoma. On reaching
the foramen ovale, if we wish to inject the ganglion, we then pull back
the metal indicator a further distance of 1*5 cm. along the stem of the
needle, so that the point can penetrate the canal and reach the Gas-
serian ganglion itself; *5 cm. of a 2 percent solution of novocain,
followed by a small quantity of alcohol, not more than i c.c., is then
slowly injected, and the resulting anaesthesia carefully observed.

To reach the foramen rotundum and second division of the nerve,
one set of landmarks given by Hartel is practically identical with those
described by myself in the Medical Annual of 1910, viz. ; The point

NEW TREATMENT

379

NEURASTHENIA

of entry is immediately below the zygomatico-maxillary future, and the
needle is pushed in along the surface of the maxillary tubercle upwards,
backwards, and inwards for a distance of 4-5 to 5*5 cm., then the point
is turned baclovards till it touches the posterior wall of the pterygo-
maxillary fossa, when it is pushed i cm. further to reach the mouth of
the foramen rotundum. An alternative route is from the front, along
the floor of the orbit itself. This is more easily accessible than the
transverse route previously described. The technique is as follows :
The point of entrance of the needle is at the lower border of the orbit,
midway between its inferior-external angle and the zygomatico-
maxillary suture. The globe of the eye is displaced upwards by the
finger, and the needle is pushed along in the space betw^een the finger
and the floor of the orbit in a sagittal direction to a depth of 4 to 5 cm.,
perforating the pterygo-maxillary fissure, and impinging on the ptery-
goid process of the sphenoid. Seen from the side, the direction of the
needle, when in the foramen, should just touch the upper edge of the
auricular muscle. Seen from the front, it should point towards the
upper and inner angle of the orbit. On reaching the foramen, the
needle is pushed a few millimetres further, and the fluid injected,
generally against some resistance, since the nerve completely fills the
foramen. The needle must be kept along the floor of the orbit.

To reach the sphenoidal fissure (through wliich the branches of the
first division emerge, together with the motor nerves of the eye), should
this be considered advisable, it is best to approach it along the outer
wall of the orbit, starting at its upper and outer angle, and passing
along close to the bone for a distance of 3 cm.

After injection of the Gasserian ganglion, the whole territory of the
trigeminal becomes anesthetic, not only the skin of the face, but the
mucous membranes of the eye, nose, mouth, and tongue, the teeth,
upper jaw, and hard palate on the corresponding side. The back of
the tongue and the soft palate escape, these being supplied by the
glossopharyngeal. There is a certain risk of ulceration of the
anaesthetic cornea, just as after excision of the ganglion.

Reference. — '^ArcJi. f. klin. Chir. 1912, ci, 193.

NEURASTHENIA, TRAUMATIC. Bedford Pierce, M.D., F.R.C.P.

Campbell Thomson^ used ‘‘ neurasthenia ” in a general sense, as a
designation for a group of functional neuroses. He maintained that
the trauma of the mind is the essential factor of the neurosis, more
especially emotion often associated with fear, and that traumatic is
not essentially different from non-traumatic neurasthenia. The
amount of shock is often out of all proportion to the degree of danger.
He laid stress on the importance of observing the length of the latent
period, i.e., the interval of time between the shock and the develop-
ment of symptoms. This in genuine cases he considered was rarely
longer than a week or two, and when, as frequently happens, symptoms
began long afterwards, they probably were dependent largely upon
anxiety, financial uncertainty, the worry of litigation, and repeated

NEUf?ASTHEN!A 380 MEDICAL ANNUAL

medical examinations. He strongly dissented from the view that all
cases reco^•er when litigation is over.

The symptoms are attributed to disorder of the sympathetic system
and the autonomic centres in the brain and sacral region ; but these
arise from the inhibition of cortical control and the over-activity of
the thalamic centres. The results of the treatment of 60 cases of un-
complicated neurosis, the patients being of both sexes and of all classes,
were as follow : 39 were able to resume work, 9 are permanently
disabled, 3 became insane, and in 9 cases the results were uncertain.

As regards treatment, he advised change of surroundings, regulation
of mental and bodily exercise, and plenty of good food and air. The
importance of ensuring complete fitness for work before attempting to
resume it, was urged. He stated that the earlier cases are treated the
better, but that some had recovered after having been on the com-
pensation list a long time.

An interesting discussion followed the reading of his paper. Savage
thought that neurasthenia scarcely existed fifty years ago, and that
it was associated vnth increasing difficulties of environment. He stated
reasons for thinking that when an injury occurred to a person in a
state of extreme excitement, or when he was drunk, there was a greater
risk of damage to the brain. Robert Jones said he had been
accustomed to regaid neurasthenia as more or less of hysterical origin,
but he new conceded that it was an organic entity with definite
symptoms, sometimes terminating in definite insanity and associated
with general paralysis. He considered it was a physical condition,
and that for every mental manifestation there was a definite material
underlying condition. IMenzies suggested that the damage to the
cortical cells which led to over-acti\’ity of the thalamic centres and
the sympathetic sy’-stem was due in the first place to disorganization
of the serum circulation wdthin the skull. He suggested that there
was a possibility that trephining the skull in an area least susceptible
to subsequent injury would result in benefit in a number of chronic
unpromising cases. Carswell said he could confirm from his own
experience that neurasthenic symptoms arose independently of morbid
desires to see a physician, aiaxieties in respect to lawyers, or any wish
to remain an invalid. Moreover, these sjmiptoms appeared four
months after the injury and the emotional shock. They consisted ot
pain in the back and in the vertex, aggravated by mental effort. To
think out an ordinary letter became difficult ; words were omitted
and mis-spelt. He had therefore become a believer in statements
made by patients about which he had formerly been sceptical.

Reference. — ^Jonr. Meni. Sci, 1913, Oct.

NOSE. (See also Nasal Accessory Sinuses ; Nose and Throat,
General Therapeutics ; Otitis Media ; Oz.ena ; Rhino-
plasty. TF. G. Porter, M,B,, F.R.C.S.

T. W. E. Ross^ has shovm by vital staining that the inferior turbinals
have an abundant and complex nerve-suppl}^, especially in the sub-
epithelial area, where severM varieties of ner\’e-endings are found,

NEW TREATMENT 38 1 NOSE

including a plexus formed by leashes of nerve-fibrils best seen towards
the anterior part of the turbinal.

Nasal Thermometry . — Brown Kelly ^ has published an important
and entirely original investigation for determining the influence of the
nose on the temperature of the inspired air. He used extremely
delicate thermometers which responded at once to the slightest change,
so that the alternations produced by the colder inspired and the warmer
expired air were at once made evident. The bulb of the thermometer,
which was bent at an angle to the stem, was introduced into the naso-
pharynx, while the stem projected from the mouth. The excursus
of temperature in normal individuals varied from 1*5° to 6° F. His
results thus differ from those of previous observers in that he showed
that the temperature of the respiratory current in the nasopharynx
was not to be attributed solely to the warming action of the nose and
nasopharynx, but also to that of the lungs.

Nasal Deformities. — [See also Rhinoplasty). Marshall^ has devised
an operation for the correction of extreme external lateral deflections,
and has performed it with good results in some thirty cases. An
incision is made, 0*25 cm. in length, directly over the nasal process of
the superior maxilla, and parallel with the normal line of the nose.
A chisel of the same width as the incision is applied to the bone, which
is then penetrated with a light blow of the mallet, care being taken not
to go beyond the bone. The process is repeated on the opposite side.
The mobility of the nasal process on each side along its entire line is
completed by fracture by means of the Asche septal forceps, one blade
of which is placed inside the nose, the other outside. If the nose is not
yet straight, the defect lying at the suture betw^een the frontal and
nasal bones, the faulty angle can be straightened by a sharp stroke
with the mallet in a dowmward direction and against the deflected side.
No splints are employed as a rule.

Carter^ has corrected nasal deformities by the transplantation of
bone. In traumatic cases, a single strip of bone is usually sufficient.
In congenital cases, and in those due to destructive disease, it may be
necessary to construct a V-shaped wedge for the support of the dorsal
strip, by introducing two additional pieces of bone. The strictest
antiseptic precautions are necessary, as primary union is a sine qua non.
A curved incision is carried from the inner end of one eyebrow to the
other, a flap is raised, and with a sharp elevator the skin and sub-
cutaneous tissues are elevated over the dorsum and sides of the nose.
A short transverse cut is also made through the periosteum over the
naso-frontal process. A portion of the ninth rib two inches in length
is now excised free of its periosteum, and is then split, the medullary
tissue is all scraped away, and from one half, a piece is shaped to suit the
deformity. The strip of bone is now introduced below the semilunar
skin flap, and the end pushed nearly to the tip of the nose ; the upper
end is anchored under the slit in the periosteum. The wound is closed
with horse-hair sutures. Occasionally additional portions of bone have
to be inserted. The author has treated 1 5 cases in this way ; there were

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MEDICAL ANNUAL

2 failures. In 2 cases the deformity remained corrected but the bone
was absorbed. In the remaining cases the bone lived {Fig. 42, a, &).

Lupus Kasi. — Bedford^ reports a case of lupus nasi in which Pfannen-
stiirs method of treatment by Nascent Iodine was adopted with
success. Sodium iodide was given internally, gr. every four hours,
and a solution was applied hourly made up of a pint of a 3 per cent
solution of lo-volume hydrogen peroxide, to which had been added
r oz. of acetic acid (B.P.). The diseased surface healed in eight weeks.

Rhinoscleyoma. — Richards® records six cases which he met with in
Egypt, \vhere the disease is not uncommon. It is a granuloma, \vhich
begins as a hard papule in the nose, and in the course of a year or two
affects the whole organ. The author treated his cases with a vaccine

Fig. 43. — Bone transplantation for nasal deformity, ids Shows the method of elevating the
skin and subcutaneous tissues ; The bone in place.

prepared from the bacillus of rhinoscleroma which vras obtained from
the tissues, but it was found to be useless. The disease does not occur
in Britain.

Malignant Disease, — Price-Brown’ advocates internal operations
for the removal of malignant growi:hs of the nose and throat, Electrical
Methods to have the preference when possible. He has treated 10
cases in this way during the last twenty? years, 7 being cases of sarcoma
of the nose. The duration of treatment {electrolysis and galvano-
cautery) is long ; repeated cauterizations having been carried out in
these cases for from two months to over two years. The results were
excellent, 4 being cured, 2 uncertain, and i d\dng of septicaemia without
return of the growth.

Nasopharyngeal Fibroma . — Joseph and Louis Ducuing® point out
that there ought not to be a set operation for the removal of this disease.
When possible, removal should be effected through the natural passages,
i.e., the anterior nares or the mouth, or a combination of the two.
WTien there are prolongations of the tumour to the ptery^go-maxillary

NEW TREATMENT

3S3

NOSE AND THROAT

region, or when sufficient access is not obtained in this way, it naust be
obtained by operative means. The authors condemn the classical
temporary resection of the upper jaw, and recommend ; (i) The trans-
maxillo-nasal route ; (2) The sub-zygomatic route, the latter solely for
pterygo-maxillary prolongations. In the first, access is obtained by
an external incision as in resection of the upper jaw, then through the
maxillary sinus to the nose.

Horgan® records two cases in which he accidentally exposed the
meninges during an intranasal operation. In the first he was opening
up the anterior ethmoidal-ceU labyrinth, in the second resecting the
septum ; in the latter case a portion of the cribriform plate was
removed. No bad effect followed in either case.

References. — ‘^Jour, Laryngol. 1913, 57; ^Ihid. 515; ^Jouv. Amer. Med.
Assoc. 1913, i, 179; ‘^Amer.Med. 1912, 623 ; Med. Jour. 1913, i, 767-;

^Ihid. ii. 741 ; ’’Jour. Laryngol. 1912, 600 ; ^Presse MM. 1912, 885 ; ^Joiir.
Laryngol. 1912, 591.

NOSE AND THROAT, GENERAL THERAPEUTICS OF.

IF. G. Porter, M.B., F.R.C.S.

Yaccines are of undoubted value in the treatment of catarrhal
conditions of the nose and throat, especially perhaps acute and chronic
rhinitis. In acute rhinitis, Allen^ states that the attack may be aborted
or greatly shortened, the danger of complications diminished, and the
risk of chroniclty done away with. Treatment may be begun with a
stock vaccine until an autogenous one is available. The following is
the dosage he advocates : pneumococcus, streptococcus, and M. catar-
rhalis 50 million, B. influenzce, B. septus, and B. Friedldnder 100 million;
four or five days later a double dose may be given, which is repeated
at weekly intervals if necessar}^ In chronic catarrhs the treatment
is similar.

Harmer,® in addition to using ordinary (non-sensitized) vaccines,
of which autogenous are preferred to stock preparations, has also
employed the sensitized vaccines of Besredka. These consist of live
organisms plus antibodies extracted from the serum. They have been
used extensively in animals, and are said to be less toxic than ordinary
vaccines, while producing immunity more rapidly. Harmer has used
only three sensitized vaccines, namely, streptococcus, pneumococcus,
and staphylococcus, and in all of them the organisms have been killed
with phenol before injecting the patient. The first dose may be 50 to
100 million, the second 250 to 500, and the third 500 to 1000. In
acute septic infections large doses should be given early and repeated
as quickly as possible, and Harmer believes that in these cases sensitized
are safer than ordinary vaccines. In acute colds they should be given
early, but after the first day till the sixth, only with great caution.

In cases of acute sinusitis, Harmer has given vaccines in a few cases,
most of which recovered quickly ; hut as he rightly remarks, it is difficult
to determine the influence of the vaccines, as these cases usually recover
quickly if treated early by a specialist. In chronic sinusitis, strepto-
coccal vaccines gave fair results, but influenzal, staphylococcal, and

NOSE AND THROAT

384

MEDICAL ANNUAL

conform vaccines were useless. He believes that in sinus cases a
vaccine given before operation is of value, and the same is true of any
major operation. In 14 cases of atrophic rhinitis, the results of inocu-
lation were unsatisfactory’'.

Logan Turner and Bolton^ have recorded their experience in 50 cases
treated by vaccines. In every case an autogenous vaccine was
employed ; the injections were given as a rule at weekly intervals ;
the initial dose was generally a small one, the second was double the
first, the third double the second, and so on. In 1 1 cases of persistent
nasal catarrh, the results were uniformly good : the discharge either
disappeared or was greatly diminished in amount. In 7 cases of
frequently recurring colds in the head there were also good results;
the acute attacks occurred with much less frequency, and their severity
was diminished. Of 9 cases of purulent rhinitis, a cure was obtained
in 5, improvement in i, and in 3 no change was observed. Of 18 cases
of ozaena, no benefit was obtained in 8, while in 10, more or less improve-
ment follo\ved. Of the 8 which were not improved, Abel's bacillus was
cultivated in 6. Of the 10 which improved, Abel’s bacillus was found
in 9, in pure culture in 6. The dose of bacillus varied from 50 to
500 million. There were 5 cases of accessory sinus suppuration
treated by vaccines, in 4 of them after operative interference with the
view of accelerating the healing ; in 3 of these they appeared to be a
useful adjunct in the treatment.

Noon,^ starting on the assumption which had been proved by Dunbar,
that pollen-toxin is a body capable of giving rise to the production
of antibodies in animals, and even in hay-fever subjects, undertook
experiments to see what degree of immunity could be produced in hay-
fever patients by inoculations of pollen toxin. He found it possible
to raise the patient’s resistance to a marked degree. Extracts of
pollen were made, and the measure of the resistance was tested with
various strengths ; having found this, doses of pollen extract were
given subcutaneously. He shelved that suitable doses increased the
immunity, while unsuitable doses either did not affect it or diminished
it. His researches were continued by Freeman,® who gave a record
of 20 cases treated by pollen vaccines. The results on the whole
were satisfactor3^

Salvapsan. — Gerber, ® m a review of the literature, finds that excellent
results have been obtained in the treatment of primary sores in the
mouth and throat, healing taking place in from three to ten days, while
secondary efflorescences disappear in twelve to thirty-sis hours, most
rapidly after intravenous injection of 0*5 to o*6 salvarsan. Equally
satisfactory results are realized in the later stages in ulcerations of the
pharynx, gummata, and malignant syphilis. In the nose also, magnificent
successes have been obtained, even in extensive destructive processes
^vhich have resisted repeated courses of treatment with mercury. In
the larynx, the secondar^^ manifestations disappear much more slowly
after the injection of salvarsan than do those in the pharynx, but it is
especially in cases of syphilitic stenosis of the larynx, both recent and

NEW TREATMENT

385

(ESOPHAGUS

old, that salvarsan has proved itself to be of value. This has been so
frequently observed, that it may now be stated as a definite rule that
tracheotomy should not be resorted to in syphilitic stenosis without
first trying the e^ect of salvarsan. It has also beeii employed in non-
s^’philitic affections of the air-passages. These may be divided into
diseases caused by spirochsetes and those not so caused. In the former
class, many successful results have been obtained, notably in cases of
Piaut-Vincent angina. In the latter, any success that has been obtained
must be attributed to a secondary infection by spirochsetes.

WTiale’ has treated sixteen cases of syphilitic disease of the nose and
throat with various arsenical compounds, and concludes that salvarsan
and its allies offer a fair prospect of arresting tertiary syphilitic lesions
of the bones or cartilages of the nose and throat, syphilitic laryngitis,
and non-ulcerative inflammations of the pharynx and nasopharynx.
When repeated injections are not contraindicated either by technical
difficulties or by unwillingness on the part of the patient, neo-salvarsan
is the safest preparation to use.

References. — Vaccine Therapy,” 4th ed. London ; -XVIIth Internat.
Congy. Med. 1913, section xv ; ^Ibid. ; ^Lancet, 1911, i, 1572 ; ^Ihid. ii, 814 ;
^XVIIih Internat. Congr. Med. 1913, section xv ; "^Lancet, 1913. ii, 218.

(ESOPHAGUS. {See also Bronchoscopy.)

W. G. Porter, M.B., F.R.C.S.

Malignant Disease. — Logan Turner^ states that out of 113 patients
who complained of difficulty in swallowing, a diagnosis of malignant
disease w^as made in 68 ; in the remaining 45 cases an exact diagnosis
was not arrived at for various reasons ; probably a number of these
were also malignant. Cancer may attack any part of the oesophagus,
but the upper and lower ends are more commonly affected than the
centre. Of the 68 cases, 62 involved the upper end and 6 the lower.
The author subdivides the first group into two sub-groups, one in
which the tumour undoubtedly involved the hypopharynx or post-
cricoid region, and the other in w’hich the disease was either con-
fined to the upper end of the oesophagus or, if it had infiltrated the
hypopharynx also, it was not evident there on laryngoscopic examina-
tion. The subdivision was made on clinical grounds because : (i) The
disease could be recognized in the hypopharynx by means of the
laryngoscopic mirror ; (2) It occurred in women much more frequently
than in men ; (3) It affected women at an earlier age than it did in
other situations ; (4) The disease \vas of shorter duration in this situa-
tion than \vhen in the oesophagus. The following subdivision was
therefore made : hypopharynx, 26 cases, or .38 per cent ; upper end of
oesophagus, 36 cases, or 52 per cent ; lower end, 6 cases, or 8 per cent.
Of the 68 cases, 26, or 38 per cent, were males, and 42, or 61 per cent,
were females. This preponderance of the disease in the female sex is
contrary to the experience of Butlin, Morell Mackenzie, and other
writers. It was specially iriarked in the hypopharynx,- i.e., 19
females to 7 males, while at the lower end of the oesophagus the male
sex was more commonly affected, i.e., 5 males to i female. The

(ESOPHAGUS

386

MEDICAL ANNUAL

incidence of the disease is younger in females than in males ; the
majority of the women were aifected between the ages of thirty and
iifty ; the majority of the men, on the other hand, after fifty years
of age.

Duration of the Symptoms. — These varied considerably ; in a few
of the cases it was quite short, and was misleading as to the probable
duration of the disease. This was due to the fact that in some instances
the patient suddenly became conscious of obstruction in swallowing ;
after this onset, dysphagia remained permanently. In the great
majority of cases it extended over a long period, varying from a few
months to several years. There is a tendency to regard some of these
long cases as functional, but Turner insists that such a diagnosis
should be emphatically condemned. The duration of the disease
varied remarkably ; this was due to the inability to fix the date at
which it probably began. In the author’s series the date of death
was ascertained in 34 cases. In 3 gastrostomy had been performed.
In the remainder no surgical interference was carried out. On
an average, death supervened in three months after the examination.
In two of the cases which had been operated upon, death occurred
within a few days, and the third terminated fatally after four months.

Semeiology. — The author has noted that pain, usually a dysphagia,
is in some cases a prominent symptom, while in others it may be
absent throughout the whole course of the disease. Its presence or
absence was enquired into in 41 cases, and it was found to exist in
34 ; while in 7 it was entirely absent. Emaciation is a prominent,
and often a rapidly progressing, feature. Cough is occasionally
troublesome. The accumulation of mucous secretion in the lower
part of the pharynx is a frequent and disagreeable symptom, and
is often demonstrable on laryngoscopy ; but the presence of blood
is exceptional. Hoarseness occurs, either as the result of involve-
ment of one of the recurrent laryngeal nerves, or from direct invasion
of the larynx by the disease. The symptom was present in 17 cases
at the time of examination, while in several others it developed at a
later date.

Physical Examination. — ^The presence of enlarged cervical glands
was noted in a number of cases, most commonly in tumours affecting
the hypopharynx. Laryngoscopy is an essential part of the examina-
tion. Abnormal secretion behind the arytenoids was observed in
13 cases. Actual changes were observed with the mirror in 43, i.e.,
63 per cent of the cases. Interference wdth the mobility of the cord was
noted in 22, or 32 per cent ; there was paralysis of one cord in 13 cases,
the right cord being affected in 4, the left in 9, while in the remaining
9, the fixation was due to infiltration of the crico-arytenoid region by
the tumour, and not to paralysis. The other changes were mainly of
the nature of tumour infiltration. In cases classified as malignant
disease of the hypopharynx, part of the tumour was visible, usually
as an ulcerated infiltration lying across the deepest part of the pos-
terior phar^mgeal wall. In addition, one or both arytenoid regions

NEW TREATMENT

387

CESOPHAGUS

may be swollen, or there may be obvious tumour infiltration of these
areas. {Plate XXVII, Fig. A, ; Plate XXVIII, Fig. C.)

The use of bougies is deprecated by the author, because when the
clinical history points to obstruction of the gullet, no further advantage
can be derived. In some cases it will enable us to say that the obstruc-
tion is situated at so many inches from the incisor teeth, but that is all
that can be gained from the introduction of this instrument. It
gives no information as to the cause, nor as to the nature of the stric-
ture, whether fibrous or malignant, or whether from pressui*e upon its
walls. Moreover the bougie is not free from danger, and fatal accidents
have followed its introduction : the instrument may be forced through
the ulcerating base of a malignant tumour and death result. The
A'-rays afford a safer and wiser procedure in determining the position
and length of the stricture, and by means of bismuth porridge and the
fluorescent screen, we may also determine whether the cause of the
obstruction is in the walls of the oesophagus itself or in compression by
neighbouring structures. Of course a diagnosis of malignant disease
cannot be made by this means ; but oesophagoscopy is necessary,
and by a combination of the two, sufficient information is obtained to
determine the possibility of removal of the strictured portion. Carci-
noma is not always readily recognized through the cesophagoscope,
and two or three examinations may be necessary ; 24 cases in the
author’s series were so examined. Where the disease could be seen by
the use of the laryngoscopic mirror, oesophagoscopy was not employed.

Bassler^ has devised a new technique of x-ra.y examination of the
oesophagus, with the object of holding the bismuth in the oesophagus,
and so obtaining a sharp outline of its walls. He uses a four-foot length
of rubber tubing, 4 mm. in diameter, to \vhich is attached a rubber bag
covered with a reinforcement of silk, and having a brass tip at its lower
end to give it weight. At the upper end of the tube is a cock. The
tube is passed in the usual manner of a stomach tube beyond a mark
about 40 cm. from the upper end of the bag, which is then in the
stomach, after which it is filled with water by means of a syringe. The
cock is closed, and the tube pulled on so that the bag is drawn into the
funnel-shaped cardiac orifice of the stomach, and the external end held
lightly at this point. A bismuth mixture is now run into the gullet by
means of an ordinary urethral catheter, and photographs are taken
with the patient standing in the lateral dorsal position with the left
back to the plate.

Surgical Treatment. — ^Willy Meyer® discusses the surgery of cancer
of the oesophagus. He insists that the moment a case is diagnosed it
should be handed over to the surgeon, and that there is hope of a
successful issue if the disease is limited to the oesophagus, for growth
is slow at first, and metastases are late in forming. The operative
method of choice is a gastrostomy by Jianu’s operation, in which a part
of the greater curvature of the stomach is dissected and formed into a
long gut-like tube, one end opening into what is left of the stomach,
the other end being free. This is drawn up extrathoracically below the

(ESOPHAGUS

38S

MEDICAL A^"XUAL

skin or pectoral muscle to a point above the mammary gland, and at a
second sitting, after resection, the oral end of the oesophagus having also
been transposed extrathoracically, the connection between the mouth
and stomach can be completely restored. This method' is available
in cases in which the carcinoma is situated above, behind, or right
below the aortic arch. When the cancer is in the lower third of the
oesophagus, intrathoracic oesophagoplasty might be performed. Be-
sides Torek's successful case {vide infra), the author refers to another,
operated on by Zaaiger^ in January, 1913.

Torek ^ records the first successful case of resection of the thoracic
portion of the oesopliagits for cancer, in a woman, aged 67. The chief
difiiculties are obtaining access, avoiding injury to the vagi, and doing
away with the risk of leakage from the proximal stump after resection.
He obtained access by carrying the incision through the whole length
of the seventh intercostal space, from the posterior end of which it was
extended upwards b}^ cutting through from the seventh to the fourth
ribs near their tubercles. The oesophagus was exposed by dividing
the pleura and drawing aside the vagi, of which some branches crossing
the tumour were divided without affecting the pulse. Great difficulty
was experienced at the site where the oesophagus passes behind the
arch of the aorta, which was dislodged and lifted forward after division
and ligation of some of its thoracic branches. The oesophagus was
then liberated from its attachments all the wa}" up to the neck,
divided below the tumour with a cautery after double ligation, and
brought out with the tumour through an incision in the neck at the
anterior border of the left stemomastoid muscle, so that the pleural
cavity should not become infected from the upper stump. The lower
portion was invaginated like an appendix stump, but two successive
purse-string sutures of silk \vere used. The thorax w'as closed without
drainage. The oesophagus, which was hanging out from the w^ound
in the neck, was placed under the skin of the chest, and its fresh rim
sutured to the sldn. After eight days, the free end of the gastrostomy
tube (gastrostomy had previously been performed) was introduced
into the cut end of the oesophagus for the purpose of feeding the patient.

Liebenneister, ® in the palliative treatment of carcinoma of the oeso-
phagus, has found Olive Oil of value when the stricture has not been
complete. He has given Morphia and Atropine half an hour before
meals ; this overcomes the spasm of the muscular walls of the cbso-
phagus. He has also found benefit result from the injection of Per-
oxide of Hydrogen in i to 2 per cent solution. A mouthful is swallowed
every hour. This treatment may be continued for w^eeks or months.

Cicatricial Strictures. — Sencert' divides hums of the oesophagus into
three classes : (i) Burns of the first and second degrees, limited to the
epithelial coat of the mucosa, w^hich heal in a few^ days leaving no
trace ; (2) Those of the third degree, in which the epithelial layer is
destroyed, healing with a cicatrix ; (3) Those of the fourth, fifth, and
sixth degrees, in w'hich the mucosa, the submucous layer, and even
part of the muscular coat, are destroyed ; here healing is ver\’ slow,

NEW TREATMENT

389

CESOPHAGUS

and ends in stricture, wliich may be complete. The author differen-
tiates clinicalh^ between cases which on oesophagoscopy are permeable
to a bougie passed under guidance of the eye, and those which are not.
In the former he gives Thlosinamine ; if this fails after twelve injec-
tions, he dilates with graduated Bougies, or treats by Electrolysis, or
internal (Esophagotomy. The last method is dangerous. In the
latter .class he advocates Gastrostomy as a first step. In many cases,
rest of the oesophagus relieves spasm and permits a fine bougie to be
passed. The author prefers a rubber tube, which he leaves in place
ten to twelve hours, replacing it by larger and larger sizes. Where
rest is not effective, he employs retrograde oesophagoscopy, and an
attempt is made to pass a fine bougie through the stricture. When
cases are seen shortly after the bum, no intra-oesophageal treatment
is permissible until after the lapse of weeks or months, when the
oesophagoscope shows the bum itself is completely healed.

Moure,® at the French Congress of Surgery, advocated slow dilata-
tion of a stricture in preference to rapid divulsion or internal oesophago-
tomy. Electrolysis was also dangerous, though it might give good
results. Dilatation by direct vision, by means of the oesophagoscope,
was of special value. Gastrostomy was of value, when dilatation
failed, by giving rest to the oesophagus and relieving spasm ; this
might be followed by retrograde dilatation. Wliere this fails, oesophago-
gastrostomy, or oesophagojejunogastrostomy, might be performed.

Sargnon and Alamartine® have treated 24 cases of cicatricial stenosis
of the oesophagus. In 3, dilatation without oesophagoscopy was success-
ful. In 7 cases oesophagoscopy followed by dilatation with bougies
was carried out. In 8 gastrostomy had to be performed, followed
by dilatation by endoscopic methods through the stomach or mouth,
or both. In 2 cases gastrostomy and internal oesophagotomy, and
in 2, gastrostomy and external oesophagostomy were performed. In 2
congenital cases the patient’s condition was too grave to allow of
operative treatment. The authors lay great stress on the value of
gastrostomy as an operation of emergency when the patient is starv-
ing, and as the operation of choice when the stricture does not yield
to dilatation through the mouth. This is followed by retrograde
dilatation.

Walker Downie^® believes that syphilis is a not uncommon cause of
oesophageal stenosis, and has observed ii examples, g in women,
out of 100 consecutive cases of stenosis of the gullet. The patients
frequently have fissures at the angles of the mouth, and glossitis, and
a history of secondary lesions may be obtained. CEsophagoscopy is
not of much aid in differential diagnosis. The condition is amenable
to treatment, which consists of Antisyphilitic remedies and Dilatation
of the stricture by bougies. Dr. Hill, in discussing this paper, was not
convinced that the author's claim of having observed ii cases of
syphilitic contraction of the gullet could be accepted. He had only
seen one case out of more than 180 examined, and Guisez had only
seen one syphilitic stricture in over 800 gullet cases.

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Peptic Ulcer. — ^Watson^^ records two cases of peptic ulcer of the
oesophagus. In the first case, where the ulcer perforated into the left
pleura, a diagnosis of perforated gastric ulcer was made ; in the
second, diagnosed as gastric ulcer, no perforation occurred. In both,
the abdomen was opened on account of acute abdominal symptoms,
and nothing abnormal was found. Both cases ended fatally.

Cardiospasm . — ^Myer and Carman^*^ have observed 14 cases of
cardiospasm, with the after-treatment in 8 of these. Cardiospasm
may be preceded by gastric symptoms, or the origin may be sudden.
In the former case, pain radiating from the epigastrium to the
hypochondriac regions, and the complaint of a “ lump in the
stomach,’' have been common. Shortly after, difficulty in swallowing
is experienced, and becomes more marked, till only fluids can be taken.
There then occurs dilatation or sacculation of the oesophagus, and
large quantities of food are eructated. On passing a bougie, an obstruc-
tion is found 40 to 45 cm. from the teeth. In order to determine
the amount of sacculation, a stomach tube is introduced into the
oesophagus with a thin rubber intragastric bag attached. Water is
gradually injected into this until the patient complains of considerable
discomfort, when the amount of water may be removed and measured,
and an idea of the degree of sacculation obtained. A normal oeso-
phagus will not admit more than 40 to 60 c.c. of fluid. Radiography
may also be employed. CEsophagoscopy is of value in the differ-
ential diagnosis from carcinoma and stenosis due to scars. The
authors have successfully treated these cases by Divulsion by hydro-
static pressure by means of a silk-rubber bag from 3 to 3*5 cm. in
diameter. In the authors’ experience, though the patient may be
made reasonably comfortable, he can never be restored to a perfectly
normal state. He must not eat rapidly, the reason being that the
sacculation persists, as the authors have demonstrated, even four
years after the ” cure.” Dilatation is carried ouit twice weekly for
two or three weeks, then each week until the symptoms have been
entirely relieved.

Lerche^® has had an experience of 17 cases. He measures the
capacity of the dilated oesophagus by means of his oesophagometer,
a large thin rubber bag introduced into the oesophagus by the aid of a
wire stylet ; the bag is distended -with air, which is drawn off and
measured. CEsophagoscopy is the most important method of examin-
ation ; it is essential to exclude lesions such as ulcer or new growth
before commencing treatment. He also treats cardiospasm by sketch-
ing the lower end of the oesophagus with a silk-rubber bag attached
to a stomach tube, which is introduced into the epicardia-cardia by a
ware stylet and distended by air or water. The author dilates to
30 mm., using about 10 lb. pressure. For the treatment of the
catarrhal condition of the mucous membrane, he has used Nitrate of
Silver solution, injected through a fine silver cannula.

Plummer has treated 91 such cases, also by dilating the cardia
wdth a hydrostatic dilator. Of these, 73 were completely relieved of

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391

OPERATION COMPLICATIONS

the dysphagia, ii were not completely cured, 3 could not be traced,
and 4 died of various causes, i from rupture of the oesophagus. The
oesophagus was dilated in the first 30 cases with a pressure of 500
to 575 mm., in the next 31 with a pressure of 675 mm., in the last 45
with a pressure of 575 to 600 mm. Usually, two or three treatments
were given, and the patients then sent home.

Eiiihom^'"’ also records several cases. One of these patients com-
plained, of nothing but cough during or immediateh^ after eating. The
authors lays special stress on the value of Meltzer’s swallowing-sound
in diagnosis ; if occurring at once, or seven seconds after deglutition,
oesophageal dilatation is not present. If delayed twelve to twenty
seconds after swallowing water, cardiospasm is frequently present.
Mild cases quickly improve under the influence of a sedative. In
severer cases the forcible stretching of the cardia by means of a
cardiodilator is essential.

Examination of (Esophageal Lesions. — Plummer^® bases his technique
on an experience of some 300 cases. He divides the methods into
three, i.e., radiography, cesophagoscopy , and the various methods of
sounding. Radiography discloses thoracic masses obstructing the
oesophagus from without, and reveals the position, size, and relations
of diverticula and dilatations when filled with bismuth mixtures. In
passing sounds, the author has found Mixter’s method of using a silk
thread as a guide of great value. The patient swallows six yards of
silk thread ; this passes down through a sufficient number of coils of
intestine to prevent its withdrawal on being pulled taut. With the
whalebone staff or olive passed on the thread, pockets ma^^ be located,
stricture dilated, and the rigidity estimated.

References. — ^Joiir. Laryngol. 1913, 281 ; ^Joitr. Amey. Med.

1913. i. 1283 ; ^Med. Rec. 1913, i, 888 ; *Beitr. z. Min. Chir. 1913, Mar. ;
^Surg. Gyn. and Ohst. 1913,1, 614; ^Munch. med. Woch. 1911, 2016; ’"‘Surg.
Gyn. and Ohst. 1913, i, 494 ; ^Rev. de Chir. 1912, ii, 71 1 ; ^Ibid. 146 ;

Med. Jour. 1912, ii, 1036 ; 1182 ; ^^Jour. Amer. Med. Assoc. 1912, ii,

127S ; ^^Anier. Jour. Med. Sci. 1912, i, 415 ; ^^Jouv. Amer. Med. Assoc. 1912,
i, 2013 ; '^^Med. Rec. 1913, i, 370; ^^Jour. Amer. Med. Assoc. 1911, i, 560.

OPERATIONS, COMPLICATIONS FOLLOWING.

Priestley Leech, M.D., F.R.C.S.

Beckman^ analyzes the post-operative complications and deaths in
a series of 5835 surgical operations performed in 1912 in the Mayo
clinic. These were all in-patients, and therefore serious cases.

Infections following surgical operations may be regarded in two
ways. First, aU patients may be regarded as infected before any
operation is performed, and when suppuration occurs the surgical
technique has failed to overcome the infection. The normal tissue
resistance to bacterial invasion may be lowered by prolonged sickness,
a severe surgical operation, or long-continued absorption from a
neoplasm ; the normal bactericidal properties of the tissues are inter-
fered with, and so the bacteria flourish. Secondly, many surgeons
regard the tissues of the body as being sterile, and if infection occurs

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MEDICAL ANNUAL

the\' at once assume the offending organism has been introduced from
outside. It must be remembered that pathogenic bacteria may be in
the tissues, or introduced from some outside source, or both, and it is
only occasionally that the source of the infecting organism can be
found. For several years every infection occurring in the clinic has
been investigated, but it is seldom that any definite conclusion has been
reached. An infection has never been traced to the suture material
used. In this series of cases, every wound that failed to heal by.primary
union was regarded as infected ; many such only discharged a few
drops of serum, and a considerable number of such cases showed no
growth in the cultures taken from this discharge from the wound.
The total number of infections was in, or a percentage of *019 for
the 5835 patients. There were no deaths. Nearly one-sixth of the
total infections followed operations on the stomach and intestines.
There were a considerable number of infections in appendicectomies,
and where a small McBurney incision was made, an infection was rarely
seen ; latterly, large incisions have been made, and the infections have
become more numerous ; but the thorough abdominal exploration
which has been made by introducing the hand through the larger
incision has more than ofiset the risk of slight infection.

Pulmonary Complications. — Embolism occurred in three cases.
There were twelve cases of pneumonia, but none could be attributed
to the anaesthetic, although ether is almost exclusively used in the
clinic.

Thrombophlebitis. — The total number of cases was sixteen. .No
causative factor was determinable. A middle course has been taken
as regards getting the patients out of bed. Most laparotomy patients
are kept in bed from eight to twelve da3’'S, except those ha\dng simple
appendicectomies, who are^ allowed to get up on the sixth or seventh
da}^ following operation. Three-fourths of the cases of phlebitis were
in the left femoral or external saphenous vein, ahd one-fourth were
in the right ; none w^ere double. It w^as not definitely determined that
patients with an infected wound are, or are not, more likely to develop
phlebitis than so-called clean cases. In only one of the sixteen cases
had the patient an infected wound. In one there was phlebitis in the
arm following an operation on a perineal fistula. The usual treatment
has been elevation of the leg, with hot applications.

Acute Dilatation of the Stomach, was only seen once in a case of chole-
c^^stostom^" and posterior gastro-enterostomy for duodenal ulcer. He
thinks this complication has been avoided by early and frequent wash-
ing of the stomach. \^Tienever a patient has vomiting or regurgitation
of bitter fluid from the stomach, although there is no real vomiting,
routine lavage is employed. Three cases only developed a mild
cellulitis.

Post-operative Embolism. — Wilson^ presents the records of fatal post-
operative embolism in the operations in St. Mary's Hospital, Rochester,
Minnesota ; from September 13, 1899, to December 31, 1911, out of
57,000 major operations there were 47 fatalities due to this accident.

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Autopsies were made in 41, and the clinical diagnosis was quite posi-
tive in the remaining 6. The mortality is 0*07 per cent, or one death
in every 1352 operations. In 36 the embolism was pulmonar}’, in 10
cerebral, and in i coronary. In 82 of the 41 cases examined post
mortem, the location of the originating thrombus was found in the
field of operation or femoral vein. In 4 cases the origin was probably
in the heart, and in the remaining 9, the source was undetermined.
Arteriosclerosis was found in 5 cases, chronic myocarditis in 1 1 , chronic
nephritis in 14, and chronic hepatitis in 18.

During the first ten years from September 30, 18S9, to September 13,
1899, out of 6000 major operations, no cases of fatal embolism were
reported. Why should one case in every 1213 die of this complication
in the next ten years' history of the hospital ? Ether has always been
the anaesthetic, the staff has not changed, and the procedure has been
the same. The only changes coincident with the increase are, first, in
the nature of the operations (in the latter ten years there have been
more operations in the stomach, gall-bladder, lower bowel, prostate,
and hysterectomies, and it is subsequent to operations on these organs
that most of the fatalities have occurred) ; and, second, in the condition
of the patient coming into the hospital and to the operating-table,
which has materially changed since the first decade. During the first
ten years a very large proportion of the surgical cases were drawn from
the general family practice of the members of’ the hospital staff, and
were operated on before they were in extremis. During the last tivelve
years the surgical material has consisted almost entirely of referred
cases, mth an ever increasing percentage of those of the “ last resort”
type, and it is this class in w^hich most of the emboli have occurred.

The most important factors concerned in extensive post-opemtive
thrombosis are as follows : (i) Injury of the vascular wall ; (2) Slowing
and stagnation of the blood-stream. After operations, the rapidity and
volume of the current in the veins are materially lessened for a consider-
able distance proximal to the first incoming venous radicles ; also the
patient is kept in a recumbent position, thus reducing the force and
rapidity of the heart’s action, and causing a general slowing of the
blood-current throughout the entire vascular system, including the
heart ; (3) Disintegration of the corpuscles of the blood from toxic
substances. It has been suggested that this factor may account for
the high percentage of post-operative emboli following gall-bladder
operations ; (4) Bacteriaemia.

The following suggestions are made for the prevention of post-
operative thrombosis and embolism. Vascular traumatism at opera-
tion should be reduced to a minimum by the conservative occlusion of
vessels, and provision of free drainage to prevent later extensive
external pressure on vessels. Very early free movement on the part
of the patient should be encouraged as soon as the nature of the opera-
tion and danger from haemorrhage will permit ; the reported results of
early getting-up after laparotomy are unconvincing as to the reduction
of post-operative embolism. Early movement may be bad if extensive

OPERATION COMPLICATIONS 394

MEDICAL ANNUAL

thrombi have already formed. The pre-operative administration of
drugs to increase the coagulability of the blood, e.g., calcium salts in
hepatic disturbances, is of questionable value so far as thrombosis and
embolism are concerned. Measures looking toward the reduction of
bacteriaemia are certainly indicated as a pre-operative precaution for
the prevention of tlirombosis and embolism. Where possible, the
preliminary destruction {as with a cauteiy’) of local foci of infection
should be considered. When the invading organism can be isolated
and identified, a preliminary’ vaccination is suggested. In some
instances, this might prove of material benefit in avoiding post-
operative infections other than those of the vascular systems.

Burnham^ comes to the conclusion that post-operative thrombo-
phlebitis is an infectious disease. It occurs at an earlier date in clean ”
than in drainage cases. Rest in Bed seems to be the only therapeutic
measure capable of exerting any marked influence on the severity
and course of the disease. Ichthyol seems to have a direct and
constant influence on the local pain.

References. — Surg . 1913. h 718; ' Ibid . 1912, ii. S09 ; 1913,

i, 131.

ORCHITIS, ACUTE PRIMARY. Frederick Langmead, F,E,C,P.

Etiology. — Acute primary inflammation of the testicle in children,
for which no definite cause is manifest, has been ascribed to masturba-
tion and to acute tuberculosis. L. Ombredanne, from observation of
seven such cases, believes that they are more correctly to be attributed
to torsion of the gland.

Symptoms. — He describes a characteristic case. A boy’, aged from
10 to 15, presents himself for pain in the scrotum, stating that it
appeared quite suddenly two or three days before. Previously, he
may have experienced it in the same position, but not so severely.
The scrotum on one side is red, oedematous, and may be adherent.
Palpation of the testicle is painful, and the boy strongly resists examin-
ation. The gland may be considerably enlarged as compared with
that on the other side. The epididymis and testicle cannot be
distinguished from one another. The vas is often swollen and tender,
especially at its lower end. There are fever, nausea, and want of
appetite. With rest in bed, the swelling may decrease and the
symptoms improve, so that in a few days the boy is discharged. In
some cases, in the succeeding months, the testicle gradually atrophies.
On the other hand, the swelling may increase and an abscess may form,
which has to be ey^acuated. Pus is found in the tunica vaginalis.
Recovery may foiloyv in a few weeks, or shreds of necrotic testicular
substance may be discharged, before the wound heals.

Treatment. — He urges that in all apparent cases of acute primary
orchitis, the likelihood of torsion of the testicle being the real nature
of the malady should be borne in mind. Since, in cases of doubt,
irreparable damage may ensue, it is unv’ise to wait, and an operation
should be performed. He recommends fixation of the tunica vaginalis

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OTITIS MEDIA

to the scrotum if the torsion is above the tunica, and fixation of the
testicle to the tunica vaginalis and the latter to the scrotum if the
torsion is within the tunica.

Reference. — '^Presse Med. 1913, 595

OSTEO-ARTHRITIS OF HIP. (See Hip, Osteo-arthritts of.)

OTITIS MEDIA. Geo L. Richards, M.D.

Adair-Dighton^ considers the nasopharynx the origin of 90 per cent
of aural diseases. Catarrh of the Eustachian tube, acute and chronic,
is the most common condition found from an inflamed naso-
pharynx. The picture of the pharyngeal orifice is important in its
diagnosis and treatment. Any acute catarrhal salpingitis can usually
be cured by an application of Silver Nitrate or any of its proprietaiy"
preparations, such as Argyrol, Sophol, or Protargol, applied directly
to the pharyngeal orifice, and if the catarrhal condition is due to
pathological lesions, such as enlarged pharyngeal tonsils, a deflected
septum, hypertrophied turbinates, or adenoids, these should first be
removed. To diagnose and treat chronic catarrhal salpingitis and
chronic atrophic salpingitis correctly, it is essential to ascertain the
patency of the tube and to know whether the pharyngeal orifice is
hyperplastic or atrophic. In chronic catarrhal salpingitis of the
hyperplastic type, the patency of the tube can be restored by first
reducing the inflammatory condition of the orifice, and then passing
bougies along the tube, and by intratubal injections of nitrate of silver
solutions. Chronic suppurative otitis media, of not longer than four
weeks’ duration and not complicated with bone infection, can be cured
by the treatment of the Eustachian tube, combined with the cleansing
of the tympanic cavity and drainage by means of position. Gyergyai-
has devised a metal dilator with which to stretch the pharyngeal end
of the Eustachian tube. It is introduced through a pharyngeal
speculum of the straight type, either that of the author or Yankauer’s.
The results in a series of cases already treated by usual methods without
satisfactory results were very gratifying, marked improvement in
hearing taking place. It is offered as an addition to, and not as a
substitute for, other methods. The dilator is moulded to the shape of
the membranous Eustachian tube, as determined by experiments on
the cadaver.

Bacteriology. — Sondern® believes acute otitic infections are due
chiefly to streptococci, with other common organisms in the following
order : staphylococcus, pneumococcus, Str. miicosus. The prognosis
concerning the possibilities of the extent and virulence of the infection
cannot be defined by the type of infection. A bacteriaemia denotes
infection of the general blood-current, but is not sufficient of itself for
a diagnosis of sinus, bulb, or vein involvement. Cases of bacteriaemia
with and without sinus phlebitis present different clinical pictures,
and the positive blood-culture does not aid in the differential diagnosis ;
on the other hand, negative blood- cultures do not exclude sinus
thrombosis, and any suggestive symptoms call for repeated cultivations.

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396

MEDIC AX, ANNUAL

Clinical observations and laboratory aids are often more helpful in
making a diagnosis than blood-cultures. The leucocyte count, particu-
larly the differential count, is of value in surgical otology, and according
to Urbantschitsch much importance is attached to the coagulation
period of the blood ; in instances where the coagulability was increased,
there was sinus thrombosis, whereas, if it was retarded, there was
none.

Dixon^ believes micro-organisms are most frequently found in acute
suppurative processes of the middle ear in the following order :
Str. mucosus capsulatus, streptococcus pyogenes, pneumococcus, and
staphylococcus. In cases in which the first of these is present even
after the pulse and temperature become normal, pain and tender-
ness disappear, the blood-count becomes normal, but an otorrhcea
exists, an exploratory mastoid operation should be performed. The
blood-count in simple acute mastoiditis will normally range to 18,000,
with an average of about 11,000 to 12,000 leucocytes. The polynuclear
count averages about 70 per cent, at times 80 per cent. . A leucocytosis
of over 20,000 indicates the presence of some complication, as mening-
itis, while one of 25,000 or over suggests pneumonia. A leucopenia
may be the first indication of typhoid fever as a complication. The
blood- count gives an excellent indication of the patient’s resistance or
the onset of complications, but little of the condition of the mastoid.
The ;tr-ray plate, when it gives positive evidence of mastoiditis, taken
in connection with the clinical S5nnptoms, settles the diagnosis, and
makes a mastoid operation imperative without delay. In either strep-
tococcal or pneumococcal infection there may be a sudden increase
in the polynuclear count, with or without total leucocytosis. In this
condition an x-id^y plate settles the question of mastoid operation,
though clinical symptoms oppose it.

Symptoms. — Exanihematic Otitis, — ^Borden® bases his remarks upon
the following clinical cases : scarlet fever 746 cases, otitis media in 1 1
per cent ; measles 456 cases, otitis in 28 per cent ; diphtheria 962 cases,
otitis in 2-9 per cent ; mixed infection 68 cases, with otitis in 44 per cent.
There were 333 autopsies. He finds that in measles, middle-ear and
mastoid symptoms occur during the height of the active process. Adults
are not very liable to mastoiditis in scarlet fever. In diphtheria, otitis
media and mastoiditis are not as active as in scarlet fever or measles,
so that the diagnosis is far more difficult to make. With active inflam-
mation in the heart, lungs, or joints, infection of the middle ear or mas-
toid cells causes the inflammation in these organs to become more active
and dangerous, but these visceral lesions are usually much relieved after
a prompt and efficient treatment of the aural inflammation. With
the appearance of active symptoms in the heart, lungs, or joints, one
or both middle ears often show marked signs of inflammation, or
rupture spontaneously. If at such times the middle ear or mastoid
cells send bacteria into the blood-stream, the devitalized organs are in
a position to absorb them, and they themselves become foci of infection,
to increase still further the patient’s toxaemia. The author cites four

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diphtheria patients who were not particularly ill upon entering the
hospital. Each improved or showed no symptoms for sixty-seven,
forty-four, eight, and ten days respectively. Then they developed
weakness or prostration, and gradually died without any definite
symptoms. The autopsies showed double acute middle-ear disease
in all ; and either single or double mastoiditis in three of the four.
Not one of them gave any reason to suspect the middle ear during life.
In view of the large percentage of aural involvement in severe and
fatal cases, the closest possible watch must be kept on the middle ear.
This will reveal many inflamed and swollen drum membranes. Once
determined, this condition is easily handled ; but as distinct sterotyped
symptoms are lacking, the observer should look carefully for the
merest suspicion of trouble in this locality, and possess sufficient skill
to note the slightest trace of altered natural conditions.

To establish drainage in a comparatively healthy patient is simple
enough, but to keep it open in a severe case is an entirely different
matter. Repeated drum incisions are often called for, and should be
resorted to as long as necessar^n Operations under ether should be
avoided as much as possible when important organs are involved ;
but the}’’ are never absolutely contraindicated when necessity demands.
The free drainage of pus with its attending toxins will do far more
good than ether will do harm. Ice-bags should never be used in
patients wdth contagious diseases. The development of symptoms in
the middle-ear or mastoid should be encouraged as much as possible.
Ice-bags and other cold applications effectually mask the symptoms.
The matter of prompt and thorough treatment cannot be too strongly
emphasized. Practically every case of brain abscess and every
infected jugular vein result from failure to diagnose and treat
comparatively simple conditions in the early stages.

Phillips® describes a type of persistent otorrhoea in children which
appears at first as an acute middle-ear suppuration, usually following
one of the exanthemata, influenza, or pneumonia. The discharge
from the onset is profuse and persistent, continuing beyond the third
to the seventh day after the temperature has become normal and the
pain has subsided, and there is no marked dropping of the postero-
superior canal wall. AMien it continues longer than three weeks and
does not yield to local measures, it suggests involvement of the aditus
and mastoid antrum, and in such cases the author has obtained
excellent results by combining the simple Mastoid Operation with
Post-auricular Drainage. In young children, when the operation has
been performed any time between four weeks and three months, the
results have been excellent. In patients with markedly hj^pertrophied
tonsils and adenoids, when the purulent otorrhoea has extended beyond
the febrile stage, it is best to delay post-auricular drainage until after
the removal of the tpnsils and adenoids. The advantages of this oper-
ation are that it terminates quickly an otherwise persistent otorrhoea
prevents a chronic purulent otitis media, insures against further exten-
sion of local bone necrosis, and restores and retains the hearing function.

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Chronic Middle-Ear Disease. — Shambaugh^ suggests, in the place
of the term “ chronic catarrhal otitis media,” the use of the terms
” chronic simple otitis media ” and ” chronic non-puriilent otitis
media,” as better expressions of the fundamental condition, which is
that of infection in the membranous lining of the middle-ear chamber,
with round-cell infiltration and thickening and subsequent formation of
fibrous connective tissue. This process is from time to time associated
with an acute infection in the nasopharynx, and at these times secretion
can usually be detected in the t5nxLpanum, not by inspection of the
drum membrane, but by inflation through the tube. The chronic
middle-ear process may or may not be associated with a persisting
tubal occlusion. The membrana tympani, even when not retracted,
usually appears more or less thickened and opaque, enough so to
indicate the type of process involving the membrane lining the
tympanum. The degree of retraction of the drum membrane is no
index to the defect in the hearing, or of the improvement to be expected
from inflation. The prognosis as regards relief of the deafness is
better if the occlusion of the tube has disappeared. Persistent tubal
occlusion indicates a still active process, and foreshadows further
increase in deafness. The presence of secondary changes in the
labyrinth, best detected by noting the defect for the higher notes of
the Galton whistle, makes the prognosis bad. The defect in hearing
found in cases of persistent tubal occlusion, especially if secretion is in
the tympanum, is more readily improved by treatment.

Tiiberctdous Otitis. — Long^ considers primary tuberculosis of the
middle ear rare, infection taking place by way of the Eustachian tube
and external auditory canal. Bacteriological examination of the
discharge will determine the localization and character of the disease.
If operation is necessary, the radical type is the only one to be
considered.

Prognosis. — Hearing Tests. — Bennett® gives the following principles
for hearing tests in connection wdth the prognosis in middle-ear diseases,
the prognosis depending very largely on the results of these tests.
While well known to aurists, they are here reproduced as being of
value for such practitioners as may desire to determine, without too
great difficulty, whether certain cases of deafness will be benefited by
treatment or not.

The normal range of hearing is between 16 and 48,000 double
vibrations per second. When there is an interference in the conduction
apparatus, hearing for lower tones is lessened or lost. When there is
an interference in the perception apparatus, hearing for the higher
tones is lost. Normal ears hear twice as long by air conduction as by
bone conduction. When the conducting apparatus is diseased, bone
conduction is longer. When the perceptive apparatus is diseased,
bone conduction is diminished, and the relative time for air conduction
lengthened.

The Rinne test depends upon the comparison of the hearing of
the tuning fork by air conduction and b}’ bone conduction. If

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hearing by air exceeds that by bone conduction in a deaf ear, it is
called Rinne positive/' and indicates a nerve deafness ; and if hearing
by bone conduction exceeds that by air conduction in a deaf ear, it is
called Rinne negative,” and indicates middle-ear disease.

The Weber test is made with a C2 512 V. fork, placing it on the
median line of the skull, forehead, teeth, or chin. When there is
disease or interference of the conduction apparatus, the sound of the
tuning fork will be accentuated on the affected side ; but if the
deafness is due to labyrinthine disease, it will be heard better on the
normal side. Often the Weber test will not lateralize.

The Schwabach test depends upon the fact that in middle-ear
disease a fork vibrating in contact with the cranial bone is heard
longer in the affected than in the normal ear. When the auditory
nerve is affected, it is heard longer by the normal ear. The fork is
struck and placed on the patient's mastoid ; when the sound ceases
it is transferred to the examiner’s mastoid. If it is then heard, it
indicates labyrinthine disease in the patient. If not heard, the
examiner first places it on his mastoid, and when the sound ceases,
places it on the patient’s mastoid. If heard by the patient after
the examiner’s normal ear has ceased to hear it, an obstruction of
sound conduction, but not disease of the auditory nerve, is indicated.
Politzer values this test as diagnostic of nerve involvement, and
prognostic for recovery under treatment when the sound perception
is prolonged through the cranial bones.

A negative Rinn6 test indicates middle-ear disease which should be
partly or entirely benefited by treatment. A positive test indicates
nerve deafness, which with a few exceptions implies an unfavourable
prognosis. The Schwabach test is based on principles which state
that when the conduction apparatus is diseased, bone conduction is
lengthened, and when the perception apparatus is diseased, bone
conduction is shortened. The Weber test is only valuable in indicating
disease of the perception apparatus in unilateral deafness when the
sound is accentuated in the normal ear. A study of a short series of
cases seems to show that tuning-fork tests are of value as aids in
prognosis when they point to middle-ear disease ; that even with
indications of a diseased perception apparatus supported by many
tests, care should be taken in giving an unfavourable prognosis until
treatment has been administered and found to be useless, and that
probably it is wrong to record the Rinne test as positive or negative ;
but that the records should show* the proportions of time thus : Rinne,
right, air, I-g- ; left, bone, The numerator tells the number of
seconds by which air or bone conduction exceeded the other, and the
denominator indicates the total time of hearing for the stroke of the
fork.

Treatment. — Theobald^® uses chiefly Mercuric solutions of 1-8000,
and frequently 1-4000, in the treatment of otitis media purulenta,
although occasionally Boracic Acid in saturated solution is more
efficient. When there is profuse discharge, the ear is syringed

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tlioroughiy vrith whatever solution is used, two or three times a day ;
but if it- is scanty, the ear is merely cleansed with a cotton pledget.
^Vhen the acute stage has passed and it is permissible, the discharge
mav be sucked out of the tympanic cavity, either by the Valsalva
method or by the Politzer bag ; then the ear is wiped out, and a quantity
of warm solution sufficient to fill the canal is poured into the ear and
allowed to remain for ten minutes, after which time the solution is
allowed to run out and the ear is dried, but not thoroughly, and a cotton
pledget is placed in the meatus. The frequency of these applications
depends upon the effects produced, but they are never applied more
than once in twenty-four hours. In chronic otorrhoea the bichloride
solution seems to be more effective, except when there is extensive
destruction of the drum-head, in which case boracic acid, or boracic
acid with Aristol or Zinc Oxide in equal parts, is more successful than
the mercuric solutions.

Yankauer,^^ in chronic aural suppuration, first removes any causative
factor in the nose or nasopharynx which may lead to infection of the
Eustachian tube. He finds about 60 per cent of his cases of middle-ear
suppuration become dry after closure of the Eustachian tube by
Gurettement. Often more than one curettement is necessary to bring
this about, and the time of healing of the ear after this varies from a
few weeks to eighteen months, the average time being about six months.
If after the closure of the tube there is secretion in the tympanic cavit}",
it is removed by dry wipings under direct inspection by the physician,
or by irrigations. If the latter is employed, the ear should be thoroughly
dried with absorbent cotton or gauze. To obtain satisfactory drainage
from the mastoid cells, it is often necessary to perform an Intratympanic
Operation which includes ossiculectomy, incision of all adhesions,
removal of part of the outer attic wall, breaking down of the processus
cochleariformis, and curettage of the Eustachian tube from the isthmus
outward. With the subsidence of organic atresia of the Eustachian
tube, granulations shrink rapidly and polypi have less tendency to
recur, the cut adhesion does not unite again, the inner tympanic wall
becomes dr^^ pale, and leathery looking, and the perforation in the
drum membrane never becomes smaller, but grows larger, so that the
only remaining portion of the drum is a narrow 'white band on the
annulus t^mipanicus.

Coates^- reports three cases of spontaneous re-formation oj ear drums
that had been almost completely destro3^ed, and over a long period of
years. Once the reparative process began, it continued spontaneously.
He thinks that under favourable circumstances even the largest
perforations may close years after the inception of the disease, and as
soon as it has entirely ceased udthin the t\mpanic cavity there is a
tendency to regeneration of the tympanum. The reason for so many
failures in restoring the continuity of the tympanic membranes lies in
the lo^cered vitality of the tissues. Before beginning active treatment,
the general health of the individual should be brought to the best
condition possible.

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Mastoiditis. — VereP^ found in 96 out of 125 cases of acute mastoiditis,
or 77 per cent, that the temperature was less than 100^ F. ; of 29 cases
in which there was a temperature of 100° or over, an intracranial
complication was found in 22, while in 2 others, septicaemia and
tuberculosis might have caused the fever. IMastoiditis of itself very
rarely gives rise to a temperature of 100° or over, and if fever is
present we must suspect an intracranial complication or some general
toxic condition.

Bryant,^^ in considering the need of a mastoid operation, is guided
by the history, the condition of the ear, the presence of general sepsis
or symptoms indicating intracranial complications, formation of an
abscess which requires surgical drainage, a skiagram of the mastoid
region, and bacteriological examination ; the presence of chronic middle -
ear suppuration which will not yield to other treatment, or is associated
with cholesteatoma, of acute middle-ear suppuration if it has become
unreasonably prolonged, or if the skiagram shows an absence of the
antral pneumatic cell system, or suppurating labyrinthitis indicates
operation. The Rontgen rays clear up a doubtful diagnosis, giving,
together with other clinical S3nnptoms, positive indications for or
against operation. Prognosis following the mastoid operation per-
formed at the earliest moment is good, with speedy convalescence,
absence of complications, and restoration of normal hearing ; delay of
diagnosis and of operation encoiurages complications.

Yates^® discusses the question of the Radical Mastoid Operation in
children, and says that the presence of foul discharge, of cholesteatoma,
of polypi or granulations, of displaced ossicles, of fistulae leading into
the attic or back toward the aditus, points to the necessity of a radical
operation. Enlarged tonsils and adenoids undoubtedly influence
acute inflammation of the middle ear, and frequently help to keep up
the discharge, but their removal wdll not cure an otorrhcea that arises
from dead bone. Children under three or four years of age wdth
chronic suppuration may, as a rule, be treated on the expectant plan.
Children from five years of age and upward with discharging ears of
two or three years’ duration, and with growing deafness on the ahected
side, w^ho have not yielded to persistent local treatment, are submitted
to the operation, which does not endanger life, will permit a useful
degree of function, and will leave no deformity. This is the thing to
choose, rather than to allow suppuration with all its uncertainties and
dangers to go on indefinitely. Yates in his technique places special
emphasis upon his incision, which begins at a point in the middle
meatus of the mastoid tip, is curved sharply backward, and ends at a
point above the meatus ; it allows the sutured edges to have support at
least in part of their extent after operation is completed. The incision
is carried through skin, muscle, and periosteum as far upward as the
lower border of the temporal muscle, where the skin only is cut through.
Where a previous simple mastoid operation has been performed, the
scar must be cut through. Elevation should not be attempted until
the periosteum is thoroughly incised and the bleeding stopped. This

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done, elevation of the whole thickness of the flap is easily accomplished
without bruising or mauling the tissue — an important factor in the
healing. In very young children when the bone’ is found hard and
barren of cells except for a small antrum lined with necrotic membrane
and filled with granulations, it is better to perform the Stacke operation
and simply clean out the antrum and middle ear, thereby throwing
them into one cavity and leaving the greater part of the mastoid cells
untouched. In children, the internal tympanic wall and the region
of the round and oval windows must not be too zealously curetted.
The plastic flap is so made that, when completed, the meatus is about
one-third larger than normal ; it is round or oval, and not noticeable.
In making the flap, the membranous canal is split up to the margin
of the concha with a straight, blunt-pointed knife, which is then turned
at right angles to this incision, and a cut is made curving to the floor
of the meatus and thereby allowing the lower flap to drop freely to the
bottom of the bony cavity. A similar cut is made upward, starting
again at the end of the first incision. Then enough fibrous tissue is
dissected away from the skin flaps to fit snugly into the walls of the
bony cavity. In case of too abundant tissue, a triangular section is
cut out, and the flaps are anchored in position by a single catgut
suture. Grafts may be used to cover these parts, or the cavity
treated by tamponing with gauze until epithelialization is completed.
For cleansing purposes, simple saline solution is preferred.

Welty,^® whose reports of excellent results as to hearing after the
radical operation with use of grafts have been referred to in previous
volumes of the Medical Annual, records further cases showing
improvement in hearing, the duration of treatment being from three
to six weeks. He states that all patients under fifty years of age who
hear a whisper from a distance of 5 ft. or less, will show improvement
in hearing, provided the operation is properly done. Patients who hear
the whisper from 10 to 15 ft. may not be improved in hearing. If the
labyrinth is intact, and the hearing for the whisper is below 10 ft.,
there is certainty of improvement.

In order to hasten the rapidity with which the mastoid wound
may be closed, various new methods are offered. Iglauer^’ takes a
flap from the temporal mastoid. The mastoid cavity being thoroughly
excavated, the original mastoid incision is prolonged upwards and
forwards into the hairy scalp. The incision, concave, and about
in. long, lies immediately anterior to the posterior border of the
temporal muscles. The scalp is dissected downward and forward,
exposing the temporal fascia, and the posterior portion of the temporal
muscle and fascia are next freed from the pericranium. A triangular
flap with the apex do^vnward is then formed by splitting off the exposed
muscle in the line of its fibres. The pedicle, being formed of the fibres
passing under the zygomatic arch, contains branches of the temporal
arteries. The flap is then rotated downward and backward into the
mastoid cavity. Should the temporal ridge be too prominent, it is
chiselled away with the underlying bone in order to pro\ide a groove

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for the pedicle, which may, if necessary, be lengthened by cutting
obliquely across some of its anterior fibres. The flap is fastened to
the periosteum by catgut sutures at the lower angle of the incision,
to which a rubber drainage tube is passed through the antrum. A
puncture is made through the scalp over the dead space left by the
removal of the muscle flap, and a gauze wick inserted. The scalp
incision is sutured, the upper sutures being tied, and the lower ones
left untied for one or two days in order to allow for drainage. The
mastoid incision is closed by interrupted sutures. Layers of gauze
are placed over the dead space, and a very firm bandage applied.

Ballin,^^ in order to bring about a similar result, has in three cases
transplanted a piece of bone with periosteum attached, from the tibia
of the patient to the mastoid wound, and then sutured it to the skin.
The portion removed is cut to fit the mastoid cavity, which must have
good granulations. This is done about ten days after the original
operation, and if the case goes well, healing is complete a few days
thereafter. The cavity underneath its bone-graft fills with blood-clot,
which later organizes into bone. For hard eburnated mastoids the
procedure is not indicated. It has so far been used in but three cases.
Preservation of the periosteum of the transplanted bone is essential.

Ross^® reports his experience of the use of Scarlet Red as an after-
dressing following the radical mastoid operation in order to hasten
epithelialization of the wound cavity. The periods varied from
twenty to forty-four days, the average being five weeks. The use of
the red ointment is best delayed until healthy granulation has been
set up by the use of bismuth gauze ; it is then applied for periods
of forty-eight hours, ribbon gauze saturated with the ointment being
the medium. An interval of twenty-four hours is left between each
application, when bismuth gauze or eucalyptus vaseline is to be used.
A temporary increase of discharge may be expected after the first
application or tw^o. The method requires careful supervision to
prevent exuberant granulations and the formation of pockets. The
contour of the cavity is well maintained, and the epithelium is strong.

]Milligan-‘^ compares various methods of treatment after the radical
mastoid operation, such as packing, alcohol drops, antiseptic powders,
cell proliferants, skin grafting, and the use of the blood-clots, and finds
the best results with the use of the Blood-clot Dressing, healing having
resulted in an average of just over six weeks in twenty cases. Second
in his preference comes application to the granulating surfaces of
one or other* of the Cell Proliferants, namety, scarlet -red, amido-
azotoluol, pellidol, azodolen, and allantoin. He advocates closure
of the Eustachian tube at its nasopharyngeal end, because closure at
its tympanic orifice is dangerous on account of the uncertain proximity
of the internal carotid artery. Curettement of the tube destroys the
mucous glands of the part, and he considers it essential to retain their
presence if the best results so far as hearing is concerned are to be
secured. Almost all attempts at effecting permanent closure of the
tympanic orifice of the tube are admitted to be failures. The mucosa

OTiTfS ft/I EDI A 404 MEDICAL ANNUAL

o£ the iiinex* tympanic wall should be treated with great respect, and, if
not degenerated, should be retained in order to secure the greatest
amount of post-operative hearing powder.

Fraser-^ reports a case of erysipelas following a case of radical mastoid
operation, and considers that it follows this operation oftener than is
usually supposed. In its early symptoms it is very hard to differentiate
from intracranial complications, as the severe headaches, tenderness
on pressure, high temperature, and slight stiffness of the neck may be
present before the erysipelatous blush appears on the skin.

Cervical Abscess . — De Carli^^ gays superficial adenitis is characterized
by a small painful tumour of rapid formation. If pus can be squeezed
out of the ear on gently pressing the neck, the diagnosis is certain.
Deep cervical abscesses, the so-called Bezold's mastoiditis, present
difficulties ; there is a slow formation of a swelling at the insertion of
the sternomastoid which tends to spread downwards and backwards,
and limitation of movement of the head. Pus is too deep for fluctua-
tion to be perceived. Left to themselves, cervical abscesses tend to
spread to the mediastinum, at first following natural ways, and then
breaking these barriers. Treatment should begin at the ear as soon
as a presumptive diagnosis can be made.

Meningitis. — Milligan^^ considers the successful treatment of otitic
meningitis to be dependent upon early diagnosis and early drainage.
Special knowledge is required in order to make an early diagnosis, and
courage to operate in the absence of the full ensemble of text-book
symptoms. The localized form known as extradural abscess is a more
common complication of acute than of chronic otitis media, and is
more often found in the posterior than in the middle fossa. All cases
of purulent meningitis are preceded by a serous stage, when a desperate
fight is made by the meninges and cerebrospinal fluid to resist bacterial
invasion. Metabolism of the products of bacterial life is such as to
destroy or partially destroy the existing carbohydrates or proteins
in the cerebrospinal fluid. There is a certain test (Kopetzky) for
determining when serous meningitis is becoming purulent. So long as
the cerebrospinal fluid remains alkaline, even though turbid, there is
reason to expect a good result from operative interference, but should
it become turbid and acid the prognosis is grave. Bacteria are not
found in films or in cultures in the early stages of the disease. It is at
the stage of the disease when the cerebrospinal fluid, although possibly
turbid, is still alkaline and capable of reducing the copper in Fehling's
solution, that Lumbar Puncture is so advantageous as a therapeutic
measure. The use of Urotropin is said to have a beneficial affect,
and to assist in keeping the cerebrospinal fluid aseptic. Its rapid
elimination, partly as formaldehyde, and the fact that it is found in
the cerebrospinal fluid soon after its administration by the mouth,
have given rise to the idea that it might possess a certain antiseptic
value. To be successful, any treatment of otitic purulent meningitis
presupposes elimination of the primary focus of infection, whether it
be a middle- or an internal-ear suppuration, or, as is so frequent, the

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two combined. The internal ear is not only by far the most frequent
avenue of infection to the meninges, but also the most dangerous,
because it leads to direct infection of the posterior fossa. Milligan
has performed Haynes’ operation (See Medical Annual, 1913, 212)
twice, but in neither case did the patient survive. His records show
37 cases of meningitis serosa so-called, with 29 recoveries and 8 fatal
cases In these 8 cases the cerebrospinal fluid became definitely
purulent, and although one or other form of decompressive operaton
was performed, it was unsuccessful. Of 14 cases diagnosed at the
time of admission to hospital to be suffering from purulent meningitis
and submitted to operation, 10 died ; in 4 of these cases it would
have been wiser to attempt no operation, while the remaining 6 had
a sporting chance of recovery. Four of the 14 recovered. Milligan
summarizes by saying that if he had a case of chronic suppurative
middle- or internal-ear disease, with the temperature going up and
arterial tension increasing, with diminishing alkalinity of the cere-
brospinal fluid and absence of copper reduction on boiling it with
Fehling’s solution, he would recommend a Decompression Operation,
because such a case was obviously tending toward purulency, and
one was justified in operating at once to prevent it.

Dan McKenzie^^ emphasizes the diagnostic importance of pain —
occipital headache associated with some rigidity of the neck. In
meningitis, one can early elicit rigidity of neck muscles. Occipital
headache, whether combined with this or not, should lead to lumbar
puncture and examination of the fluid.

Day reports the results of operative treatment in 53 cases of diffuse
suppurative otitic meningitis ; 4 recovered, 3 after operation, and i
after vaccine therapy. One of the operation cases died later from a
reinfecting meningitis. Seven cases were complicated by sinus throm-
bosis, 10 by purulent labyrinthitis. In 48 a Mastoid Operation, either
simple or radical, was performed, supplemented in 33 cases by other
procedures directed to the infected meninges ; in 10 cases by dural
drains ; in 8 by simple incision of the cisteriia magna ; in i by
drainage of the lateral ventricle ; in i by lavage of the ventricle ; in
4 by intraspinal injection of urotropin solution ; in 2 by intraspinal
injection of oxycyanide of mercury.

For diagnosis, lumbar puncture gives us the most reliable information
as to the condition of the meninges. Slight turbidity cannot be
accepted as a positive sign of a diffuse process, for it may result from
a very limited area of infection. In serous meningitis a slight turbidity,
with a markedly increased number of polynuclear leucocytes in the
presence of pyogenic organisms, indicates an extensive involvement
and a correspondingly hopeless condition. It has been said that the
findings from examination of the spinal fluid might under certain
conditions lead to a diagnosis of a condition more serious than that
really existing, but Day did not find this to be so. In three cases,
the examination of the spinal fluid led to a correct estimation of the
gravity of the brain condition. In these, repeated punctures showed

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a slightly clouded fluid, non-pathogenic bacteria, and leucocytes, but
no infective organisms. On post-mortem examination, streptococci
were obtained in abundance, both by smears and culture from the
dural spaces. The bacteriology of the primary aural infection offers
no indication for or against operative interference. The organism
found in the ear at time of examination will not always be identical
with that in the dura. This is especially true in chronic purulent
otitis media.

The cases were treated by operation, either alone or in combination
with injection of drugs into the spinal canal; vaccines, and sera. The
treatment of suppurative meningitis by the administration of drugs
has proved useless, with the possible exception of the use of Urotropin
as a prophylactic. Theoretically, surgery should give relief.
Practically, the mortality has not been changed by it. Urotropin
was used intraspinally in four cases. Three of these had streptococci
in the spinal fluid, and one pneumococci. There was improvement in
only one case, a streptococcic. Intraspinal injections of oxycyanide of
mercur}? were used in two cases, but without results, for any benefit
derived in the meninges from the drug were offset by inflammation in
the bladder and kidneys, acute enough to cause early death. The
results of vaccine therapy have been such that it has been discontinued.

Operative procedure in otitic meningitis should aim (i) at prophy-
laxis, and (2) at radical cure. A prophylactic operation eradicates
the primary focus in the middle ear and adjacent bony cavities, thus
preventing the spread of infection to the meninges. As a curative
measure, when meningitis has actually developed, it is of little use in
arresting the inflammation. With no signs of infection beyond the
temporal bone, no useless exposure of the dura to possible infectioxi
should be considered. As to the use of the Dural Drain, it has been
concluded that it does not satisfactorily lessen the inflammatory^ action
over the base of the brain or spinal cord, or drain the central lobe of the
cerebellum {Plates XXIX, XXX), It is effective, but to a limited
extent. When used in the circumscribed form of the disease, it should
and does give good results. The successful cases reported in the
literature are probably of this class.

Smith^® reports upon five fatal cases of meningitis in children, having
as their cause a serious suppurative otitis media to which too little
attention was paid until meningitis supervened. Suppurative otitic
meningitis is practically incurable, and therefore, as a preventive
measure of any cerebral complications, this author urges early operative
inter\"ention before such complications develop. If the infective
process does not extend beyond the dura, a circumscribed serous
meningitis results which yields promptly to surgical intervention ;
but if allowed to spread or become purulent, an encapsulated meningeal
or cerebral abscess, or diffuse purulent meningitis, results. Kotz^’
reports three cases of otitic meningitis as healed. Careful study
w’ould seem to place them under the class of labyrinthine trouble with
certain meningitic symptoms, rather than actual cases of meningitis.

PLATE XXX,

STREPTOCOCCIC MENINGITIS

Showing the distribution of the yellowish exudate. Drainage of the cisterna magna. Later
aiitopsies would indicate that the area within the dotted lines is not influenced by this drainage.
(Ewing W. Day): Kindly lent by the Journal of Stnxcry^ Gyntecology, and Obstt-lr/is.

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Emerson^® reports a case of temporosphenoidal abscess having some of
the signs of a purulent meningitis. The Haynes operation was done,
and recovery took place. This can hardly be considered, however,
as a pure case of meningitis cured by operation, as the presence of a
large cerebral abscess made the diagnosis of a general meningitis some-
what uncertain. Three or four weeks after the operation, slight
blocking of the cisterna magna caused hiccough and vomiting. In
case of brain abscess, it is very important to keep careful watch of the
drainage even for weeks after the operation, and the cigarette drain
is the ideal method.

Sinus Thrombosis. — Downey^® considers chills, fluctuating tempera-
ture, and sweating as indications of infection of the lateral sinus. Other
signs may be absent or obscured. The question of operation may have
to depend upon the temperature curve alone. The streptococcus is
the usual organism. A blood culture is of help in making a diagnosis,
but thrombosis may exist without a characteristic blood picture.
A marked increase in the leucocytes up to 10,000 or 12,000 per c.mm.,
with a relative increase in the polymorphonuclear neutrophiles, is of
diagnostic value. McCaw®° does not believe in surgical interference
in sinus thrombosis in the absence of clinical symptoms pointing to
septic absorption. Frequent blood-counts should be made.

Roy 31 reports a fatal case of bilateral sinus thrombosis resulting
from direct infection from the external auditory canal, as determined
by autopsy. It occurred at almost identical points on both sides, the
pus passing from the emissary veins which empty into the lateral sinus
at the masto-occipital suture. Cases of complication arising from
furunculosis of the external meatus are rare, and the author urges
that they should receive more consideration as a possible source of
brain complication.

Crowe® 3 offers a mechanical test for the diagnosis of thrombosis of
the sigmoid sinus or jugular bulb. If the. internal jugular vein is
compressed with the finger, no appreciable evidence of stasis is seen in
the retinal or supraorbital veins ; but if both internal jugulars be com-
pressed at the same time, there ensues a’marked dilatation of the veins
of the fundi and of the anastomotic vessels connecting the intracranial
with the extracranial venous circulation. If now the pressure be
suddenly released on one side while it is being maintained on the other,
the engorged veins of the anastomotic system and of the fundi will
empt^^ immediately. Should the results in any individual case differ
markedly from those, it must be concluded that there is either an
anomaly of the intracranial venous circulation, or some pathological
condition which is obstructing the outflow of the blood. During this
examination the patient should breathe freely and naturally. The
collar should be loosened so as to expose the neck and upper part of
the chest. The fundi should be examined by the direct method, or
■with an electric ophthalmoscope, while an assistant compresses the
jugular veins with the tips of the finger. The compression should not
be maintained longer than absolutely necessary, for it may be possible

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in this "*vay to rupture a diseased vein or dislodge a portion of the throm-
bus (Plate XXXI), Among clinical conditions associated with an
obstruction to the outflow of blood from the brain, the formation of a
thrombus in the sigmoid sinus, secondary to an infection of the middle
ear, is by far the most frequent and important. Sinus thrombosis,
appeal's with equal frequency as a complication of acute and chronic
otitis media, and not infrequently the diagnosis offers great difliculty.
Owing to the anatomical position of the jugular bulb in relation to the
middle ear, it is possible to have a primary bulb thrombosis, with the
sigmoid and transverse sinuses normal in appearance ; and the condition
may not be recognized even at an exploratory operation. One of the
cardinal symptoms of sinus thrombosis is a remittent fever with chills,
due to the serious nature of the malady. It is desirable to know at an
early stage whether the symptoms are due to a sinus thrombosis, or
to other conditions such as angina, pneumonia, malaria, the initial
stage of one of the infectious diseases of children, meningitis, or brain
abscess.

Ballance and Hobhouse^^ find thrombosis of the cavernous sinus
occurring from frontal or sphenoidal sinus infection, from cellulitis of
the face, carbuncle of the neck, meningitis, sarcoma of the base of the
skull, marasmus, traumatism, and from extension of septic processes
from the sigmoid sinus or petrous bone. The cause of the infection
of the cavernous sinus must be determined before the appropriate
operation can be determined, for the infection is continuous, and should
be followed from its origin to its ultimate extension. When the
posterior end of the cavernous sinus is infected in temporal bone
suppuration, the Hartley-Krause method for exposing the Gasserian
ganglion is adopted ; but when pus has been evacuated from the sinus,
the Voss method of cutting away the zygoma and removing more bone
from the basal aspect of the skull to secure direct drainage is used.
Operation on the cavernous sinus should be done at an early stage, to
prevent the infection from reaching the opposite sinus through the
circular and transverse sinuses, and meninges. In osteomyelitis of
the petrous, the bone is removed piece by piece, irrigation of one or
both petrosal sinuses being insufficient. The cutting away of the
whole petrous includes exposure, and if necessary, deliberate opening
of the petrosal sinuses. It is of advantage to bring the posterior end
of the cavernous sinus directly into the field of operation.

References. — '^Ann. Otol. 1912, Dec. ; -Dent, med. Woch. 1913, June ;
^Ann, Otol. 1912, Dec.; ^Ibid, 1913, June; ^Bost. Med. and Surg. Jour.
1913, Feb. ; ^Med, Rec. 1913, July; ”Jour. Amer. Med. Assoc. 1913, Sept. 27;

Otol. 1913, June; ^Med. Rec. 1913. Jan.; ^^Ann. Otol. 1912. Dec, ;

^Maryngoscope, igi June; Jour. Laryngol. May ; ^^Ann.
Otol. 1913, June ; ^^Amer. Jour. Siirg. 1913, Aug. ; ^^Joitv. Amer. Med. Assoc.
1913, Sept.; Laryngoscope, May; ^^Med. Rec. 1913, Mar.; ^^Jour.
Laryngol. 1913^ Apr.; Med. Jour. 1913, Sept. 20; ^"^Jour. Laryngol.

1913, Sept, ; '-^Jouv. Laryyigol. igi^. -^Ibid. Moy ] ^^Tbid. ; ^°Stirg.

Gyn. and Ohsi. 1913' Apr.; -^Ann. Otol, 1912, Dec.; ^LMiinch. med. Woch.
1912, Dec.; --Jour. Anier. Med. Assoc. 1913, Sept. ; ^^Ann. Otol. 1912, Dec. ;

Johns Hop. Hosp. Bull. 1912, In^ov.; Otol. 1912, Dec!

NEW TREATMENT

409

OVARIAN TUMOURS

OTOSCLEROSIS. Geo. L. Richards, M.D.

Lake^ considers that brilliant results may be obtained trom the
Use of Radium in early case's of otosclerosis.

Reference. — ^ Ann . OtoL 1912, Dec.

OVARIAN TUMOURS. Victor Bonney, M.S., M.D., B.Sc., F.R.C.S.

Bryden Glendining, M.S., F.R.C.S,

Treatment. — Bai*rett^ discusses the treatment of ovarian tumours
complicating pregnancy, labour, and the puerperium, in a review of
1 14 cases. Seventy-six cases were treated by operation during
pregnancy, with only 3 deaths — a mortality just under 4 per cent ;
while of the 38 cases treated expectantly, 8 maternal deaths resulted
— a mortality of 21 per cent. Of the 73 surviving cases treated by
operation, 63 went to term ; in i hysterectomy was done, as pregnancy
was not suspected, which leaves only 9 abortions, in spite of the fact
that in many cases there was torsion of the pedicle, infection, or incar-
ceration. Of the 38 cases treated expectantly, only 7 escaped operation;
4 of these died, while the 3 remaining still have the tumour to be dealt
with. Eight were cases of double ovarian tumour, and out of these
8 double ovariotomies, 6 went to term, this evidence contradicting the
opinion that pregnancy cannot continue without the corpus luteum.
He quotes a case in which both ovaries were removed with the corpus
luteum ; this was followed by a normal delivery of a living child at
term 260 days after the operation.

He considers that the tumour should be removed as soon as possible
after its discovery ; this treatment gives a high percentage of good
results to mother and child, and avoids the dangers during labour and
the puerperium. Induced abortion with its 100 per cent foetal mortality
is unjustifiable, as is also the tapping of a tumour either through the
abdominal wall or vagina. Great care should be exercised in manipu-
lations of the uterus during operation, but it shows such toleration that
the necessary handling, even to stitching, need not be feared. Owing
to the great risk of torsion and degenerations during the puerperium,
an ovarian tumour should be removed as soon after labour as the
patient’s condition and surroundings ^vill allow.

Jones- considers that ovarian cysts produce serious trouble sooner or
later, especially during pregnancy, labour, and the puerperium, the
most dangerous period being the latter. Torsion of the pedicle is the
most common accident. Though the multilocular cystadenoma is the
most common form of cyst of the ovary, dermoids seem to produce
serious trouble proportionately more frequently. In general he thinks
that ovarian cysts should be removed as soon as possible after they are
discovered ; the only exception being for tumours not discovered until
after the fifth or sixth month, when the operation should be deferred
until the child is viable. He considers that expectant treatment and
aspiration of the cyst are unjustifiable. Ovariotomy has a mortality
far lower than that of any other treatment.

References. — "^Surg. Gyn, and Obst. 1913, i> 28 ; -Ibid. 63.

OZ^NA

410

MEDICAL ANNUAL

OZ^NA. IF. G* Porter, M,B,, F.R.C.S,

Etiology. — Hofer^ has investigated the connection between Perez’s
bacillus and ozaena. He found the organism in a considerable
number of cases ; and also, after its injection into guinea-pigs,
changes were produced in the nasal cavities comparable to those
found in man.

Treatment. — ^\V. Abbotson^ has treated twenty cases of atrophic
rhinitis with Reniform, which is an almost odourless substitute for
iodoform. It was used as a paint or spray in a 0-5 per cent
solution in olive oil or glycerin. The author found it tended to
reduce crusting, and mitigated the smell. No ill-effects resulted
from its use.

Moure,® in reviewing various methods of treatment for ozsena, espe-
cially recommends the injection of Paraffin into the inferior turbinals,
with a view to compensate for the atrophy of the parts. Auerbach^
has treated 32 cases of ozaena by this method. The site of the
injection may be the inferior turbinal, the septum, or the floor of the
nose. Twenty-six cases were markedly improved ; but 6 could not
retain the paraffin, and ^vere not affected.

Jacobs® has found Scarlet Red of value in the treatment of
ozaena. He used it in a suspension in mucilage of acacia of 5 per
cent strength. The nasal ca\dties w^ere first cleansed thoroughly
with Dobell’s solution. The suspension of scarlet red was then
rubbed vigorously over the mucous membrane of every part of the
nose. The treatment was carried out every second or third day
at first, and at longer intervals as the condition improved. After
two or three weeks, improvement was noted. Of 20 cases treated
in this way, all were benefited.

References. — ^Wien. Min. WocJi. 1913, loii ; -Med. Press and Give.
1913. i, 658 ; ^Berl. Min. Woch. 1913, 861 ; ^N.Y. Med. Jour. i9i3> n. 566 ;
^Ibid. i, 1143.

PAKGREAS, FUNCTIONAL ACTIVITY OF. Oskar C. Gruner, M.D.

The study of pancreatic ferments by a special method of obtaining
duodenal contents has provided a considerable fund of infonnation
valuable for application to clinical diagnosis. It has seemed more
rational to examine the contents by this direct method than to rely
upon the finding of glycosuria or the appearance of fat or even
pancreatic ferments in the stools. The subject has received careful
consideration at the hands of Crohn, ^ who uses the Einhom duodenal
pump for obtaining the secretions, and follows a definite ritual. The
patient swallows the capsule at the end of a rubber catheter at S p.m.,
aided by a little -water. At midnight die drinks eight ounces of milk,
in order to allow the capsule to pass the. pylorus. At 6.30 a.m. he
drinks eight more ounces of milk, and at 9 a.m. the catheter is slightly
withdrawn up to the So c.c. mark, and is allowed to stand there for
five minutes, after which the contents of the bucket are aspirated
They should be golden yellow, slightly acid or neutral, rather viscid.

NEW TREATMENT

PANCREAS, DIAGNOSIS OF

41 1

with a more or less opalescent hue. The apparatus is now withdrawn
into the stomach, and the contents are aspirated.

Procedure of Analysis. — ^To the contents of the first part an e^ual
quantity of distilled water is added. This is divided into two portions,
A and B. Portion A is kept acid and on ice for five hours ; then
tested for amylase and lipase. Portion B is alkalinized with decinormal
soda and put on ice for five hours ; then tested for protease.

Test for Amylase. — ^To successive c.c. add *5, i, 2, 3, 4, 5, and 6 c.c.
of I per cent starch solution, making all up to 10 c.c. with water.
Incubate them one hour, and the number of c.c. of starch in the
last tube that fails to react with iodine multiplied by 3, indicates
the amylolytic power of i c.c. of duodenal contents in an hour, the
normal being 2.

Test for Lipase . — i c.c. juice, with 10 c.c. water, i c.c. ethyl butyrate,
I c.c. toluol, and i drop of i per cent phenolphthalein are neutralized
with decinormal soda and made up to 25 c.c. with water, shaken for
fifteen seconds, and neutralized again. A boiled juice should be
used as the control. Incubate for twenty-four hours, titrate for
free acid. The amount of free acid in the test flask, less the free
acid necessary to bring the control to neutral, multiplied by 3,
indicates the lipolytic strength. The normal is equivalent to i to
3 c.c. of decinormal soda.

Test for Protease. — ^Use Mett’s tubes — capillary tubes containing
egg white, and dipped in boiling water to coagulate the contents, — or
cubes of egg white ; these are placed in the fluid to be tested. Evidence
of ferment action in a suitably acid medium lies in the partial solution
of the cubes or of the contents of the tube.

The amount of the ferments varies from day to day. The points
to note are occasional absence of lipase or amylase. The value
of the study lies in the determination of patency or othenvise of
the ducts.

Reference. — '^Amer. Jour. Med. Sci., 1913, i, 393.

PANCREAS, LABORATORY DIAGNOSIS OF DISEASES OF. {See also
Fmcbs, Examination of.) O. C. Gruner, M.D.

1. The detection of diastatic ferment in the urine is of value in
estimating the presence of interstitial pancreatitis. {See also Urine
Tests.)

2. Estimation of diastase in the faeces. Rotky^ made a study of this
subject, using Wohlgemuth’s method. The material was dried and
powdered, and the total nitrogen estimated before and after dialysis.
The unit employed was the number of c.c. of *5 per cent starch
solution that were hydrolyzed by one gram of powder. If there were
much less than 100 units, it seemed likely that one could assume impair-
ment of pancreatic function.

From the results obtained by this author, the following table may be
dra'wn up, in order to show at a glance the results of analysis of duodenal
contents that are to be expected in different states : —

PANCREAS, DIAGNOSIS OF

412

MEDICAL ANNUAL

Condition of Patient

Amjdase

Lipase

Trypsin

Xormal pancreas

-L.

Degeneration of pancreas
Obstruction of pancreatic

trace

■-I-

duct

0 (not
constant)

trace

(temporary)

Acute pancreatitis

diminished

4- (not constant)

Pancreatic anomaly

Cancer of stomach

no ferments

Achylia gastrica

+ (in gastric
juice)

Gall-stones

-f-or-h -f

Diabetes

4 -

Reference. — ^Miiuch. med. Woch. 1913, 215S.

PANCREAS, SURGERY OP. Sir Berkeley Moynihan, M,S,, F.R.C.S,

Harold XJpcott, F,R,C,S.

Bittorf^ reports two cases of abscess of the lesser sac followmg pan-
creatitis in elderly men who had suffered from abdominal symptoms.
He describes the signs under the following headings : (i) General.
There is marked wasting, slighi fever, and moderate leucocytosis.
(2) Local. A circumscribed tender tumour is found in the epigastrium,
chiefly to the left or the mid-line ; it is dull on percussion, but may be
crossed by the resonant stomach, and is separated from the liver by a
band of resonance. In one of his cases, the abscess contained gas and
was resonant. (3) Pressure signs. There may be compression of
stomach or duodenum ; jaundice from compression of the common
bile-duct ; ascites or cedema of the lower extremities from pressure
on the portal vein or inferior vena cava. (4) Pancreatic. Such are
severe attacks of pain in the epigastrium ; evidences of pancreatic
insufficiency are less common.

An accessory pancreas is a small nodule, sometimes as large as a
filbert, situated somewhere in the wall of the alimentary canal. It is
most often found in the wall of the stomach ; .in the wall of the duodenum
but detached from the true pancreas; in the first[8 inches of the jejunum,
its most common location; or in the lower jejunum or ileum. Histo-
logically it shows typical pancreatic structure and well-defined ducts.
According to Carwardine and Short,^ it may give trouble in four ways :

(1) It may produce mechanical alterations in the walls of the alimentary
canal {a ring round the duodenum or traction diverticula). In no
recorded case do these alterations appear to have caused symptoms.

(2) It is liable to acute pancreatitis, the sole recorded instance of this
being Short’s case. (3) It may develop chronic interstitial pancreatitis.
(4) It may complicate the diagnosis of the cause of abdominal
symptoms.

The first of Carwardine and Short’s cases was a girl of 12 who had
been ill four days with vomiting, diarrhoea, and the passage of blood

NEW TREATMENT

413

PANCREATITIS

from the rectum. The abdomen was not distended or rigid. There \Yas
a little pain and tenderness in the upper abdomen ; pulse 80 ; tempera-
ture subnormal. After opening the abdomen, the first 6 in. of the jeju-
num were bright scarlet in
colour, with greatly thick-
ened walls. The mesenteric
vessels were not blocked.

About in. from the duo-
deno-jejunal flexure, in the
wall of the jejunum, was a
white nodule projecting
slightly under the serous
coat. There was no periton-
itis, fat necrosis, or lymph
clot. This little tumour
was excised and the opening
in the bowel sutured. As
this obstructed the lumen,
a gastro-enterostomy was
done. Death occurred about
fifty hours later. The ex-
cised nodule proved to be
an accessory pancreas in a
state of acute inflammation.

In the second case, a nodule
was excised from the jeju-
num {Fig, 43) during the course of gastro-enterostomy, which consisted
of pancreatic, tissue but was apparently not causing symptoms.

References. — ''•Mitth, a, d. Grenzgeb, d. Med. u. Chiv. 1913, 109 ; KAmi,
S%irg. 1913, i, 653.

PANCREATITIS, ACUTE. Robert Hutchison, M,D„ F.R.C.P,

Diagnosis. — In distinguishing cases of acute pancreatitis from
acute intestinal obstruction, Todd^ attaches great importance to the
presence of absolute dullness in both flanks, unaltered by any change of
position, wdiich occurs in acute pancreatitis only. It is due to the
presence of coagulated and partially digested blood in the kidney
pouches.

Nagy, 2 from the study of a case verified by operation, concludes that
in acute pancreatitis there is no change from normal in the relative
percentage of the nitrogenous constituents of the urine. Investigation
of the tryptic and amylolytic ferments does not yield trustworthy
results. On the other hand, he is able to confirm the fact that disturb-
ance of pancreatic function may safely be inferred when fat-splitting
falls below 70 per cent.

References. — '^Austral, Med. Gaz, 1913, 279 ; ^Wien. klin. Woch, igiSt 3 ^ 7 ’
PARALYSIS, GENERAL. (See Syphilis, Cerebrospinal.)

43.— Accessory pancreas in the jejunum excised
during operation of posterior gastro*jejunostomy (repre-
sented as bisected into the bowel).

PARATYPHOID FEVER

414

MEDICAL ANNUAL

PARATYPHOID FEYER. E, W. Goodall, M.D,

An interesting account of 12 cases of this disease (due to infection
with B. paratyphosus B) has been recorded by James WattA They
were found in an epidemic of 112 typhoid cases in Aberdeen in the
autumn of 1912. Probably they would have been set down as typhoid,
had it not been for careful study of the serum reactions. In two
cases the paratyphoid fever was followed by an attack of typhoid.
The writer suggests that they received the latter infection in the
hospital, where they were being treated along with typhoid cases.
Similar cases have been observed by Scott, ^ in Jamaica. Possibly
systematic examination of all t57phoid cases would show that some
of the " relapses were not really relapses, but attacks of typhoid
following upon paratyphoid. Ten of the 12 cases showed the
first signs of illness between the dates Oct. ii and Nov. 11, 1912 ;
7 of them lived in the same quarter of the town, and 8 obtained
their milk from a common source. Most of the typhoid cases showed
their first signs of illness between Sept. 22 and Oct. ii. The facts
point to an epidemic of paratyphoid separate from that of typhoid,
or to an epidemic of the one within that of the other. The symptoms
in these 12 cases were like those seen in mild or moderate attacks
of typhoid.

Three cases of the same disease have been described by John Hay,®
of Liverpool. Clinically they differed considerably. The first began as
an ordinary acute food poisoning. There wras temporary recovery, and
then a serious and fatal relapse, characterized by S5mptoms differing
markedly from those of the initial illness. The second presented some
of the features of enteric fever, but the clinical evidence was not
sufficient to justify a positive diagnosis. The third began suddenly
with symptoms very characteristic of influenza. There was a transient
recovery, followed by a tedious febrile illness.” Hay’s second case
was fatal as well as the first, and from the account given of the serum
reactions it appears to have been a mixed infection. The third case
was interesting because a rash appeared, consisting at first of
rosy-red papules, which later became almost confluent over the scapula,
sacrum, and buttocks. Large' raised scarlet papules appeared also
over the backs of the wrists and hands.

An exhaustive account of the etiology and epidemiology of B. para-
typhosus B has been published by Job,^ with a very complete
bibliography.

References. — ^Lancet, 1913, ii, 130; ^Pract. 1913, ii, 589; ^Med. Press
and Circ. 1913, i, 494 ; ^Pev. de Med. 1913, i, iSi.

PAROTITIS. (See also Mumps.) Frederick Langmead, M.D., F.R.C.P.

M- H. Gordon’- describes four cases of fatal disease, of which the
chief manifestation was acute interstitial parotitis. All the patients
were children, between two and nine, admitted to hospital during May
and June, 1913. One child died within twenty-four hours of the onset ;
this was clinically a case of convulsions.” The others died on the

NEW TREATMENT

415

PEDICULOSIS CAPITIS

second, tliird, and fifth day respectively. Three_out of the four patients
were drowsy at the onset of the disease. All developed coma. One
was delirious. The eyes were sunken, and fixed or staring in every
case, but neither squint .nor any fun dal changes were remarked.
Muscular rigidity occurred in all, and in two the head was retracted.
Kernig’s sign was present in three. Three of the patients had twitching,
and two had attacks of more or less general muscular rigidity, in the
course of which they died. The plantar response was extensor in
two, while three lost their knee-jerks and abdominal reflexes. Pallor
was marked, and pyrexia, vomiting, and diarrhoea occurred in all.
The cerebrospinal fluid was under considerable pressure, and showed an
increase of cells, lymphocytes predominating. In one a leucocytosis
of 28,000 occurred in the blood, a differential count showing definite
lymphocytosis. Post mortem there was a slight degree of meningo-
myelitis, and foci of acute interstitial inflammation of the salivary
glands were found in all four cases, though there had been no obvious
parotitis clinically. No bacteria were grown from the heart's blood
or cerebrospinal fluid. Since poliomyelitis is known to be associated
with an acute inflammation of the salivary glands of a similar form,
it may fairly be argued that these were cases of a rapidly fatal form
of that disease. Gordon holds the contrary view, however, because no
paralysis of a group of muscles was noted during life, and the micro-
scopical lesions of the cord most characteristic of poliomyelitis were
not found after death. He regards these cases rather as the result
of the unusual action of the virus of mumps, from which disease none
of the patients had previously suffered, but suggests also that they
may be examples of a new pathological and clinical entity.

Reference. — "^Lancet, 1913, ii, 275.

PEDICULOSIS CAPITIS. E, Graham Little, M.D„ F.R.C,P.

Whitfield^ gives the following directions for the destruction of pediculi
capitis in children over five. It is especially useful in females who
object to cutting the hair : —

“ The patient is laid on her back on the bed with the head over the
edge, and beneath the head is placed a basin on a chair so that the hair
lies in the basin. A solution of 1-40 carbolic acid is then poured over
the hair into the basin and sluiced backwards and forwards until the
whole of the hair is thoroughly soaked with it. It is especially necessary
that care should be taken to secure thorough saturation of the hair
over the ears and at the nape of the neck, since these parts are not only
the sites of predilection of the parasites, but they are apt to escape
the solution. This sluicing shall be carried out for ten minutes by the
clock. At the end of the ten minutes the hair is lifted from the basin
and allowed to drain, but is not dried or even very thoroughly wrung
out. The whole head is then swathed with a thick towel, or better,
a large piece of common house-flannel, which is fastened up to form a
sort of turban, and the head is allowed to remain like this for an hour.
It can then be either washed or simply allowed to dry, as the carbolic,

PEDICULOSIS CAPITIS 416 MEDICAL ANNUAL

being volatile, quickly disperses. At the end of this period every
pediculus and, what is more important, every ovum, is dead, and
although the ova are left on the hair they will not hatch, and no relapse
will take place unless exposure to fresh contagion occurs. Incidentally,
any impetiginous scabs are softened, so that they come away easily and
allow any ointment which is used for the cure of tliis complication to be
applied easily. In cases where there is no impetigo no further treat-
ment is necessary."' [See also Skin, General Therapeutics of.]

Reference. — ^ La 7 icet , 1912, ii, 1648.

PELLAGRA. Leonard Rogers, M.Z).,

In view of the discovery of a number of cases of pellagra in Great
Britain during the past year, a brief general account of the disease is
likely to be of considerable interest to our readers. The following
description is mainly based on Roberts's recent work on pellagra, and
the article in the last edition of Castellani and Chalmers" Tropical
Medicine,” together with recent papers on the disease.

Definition. — Roberts defines pellagra as an endemic and epidemic
disease, periodic and progressive in its course, and characterized by a
series of symptoms involving chiefly the digestive, cutaneous, and
nervous systems.

History and Distribution. — Casal wrote the first full description
of the disease as seen in North Spain in 1735 (although his work was not
published until 1762), calling it mal de la rosa, and the affection is
prevalent in Asturias to the present day. In the same century the
disease was well known in Italy, where it is still very common ; and
in the latter part of the nineteenth century Lombroso closely studied
it, and strongly supported the view that it was produced by mouldy
maize. Portugal, France, Austro-Hungary, and Roumania have all
reported numerous cases, while as long ago as i860 it w^as recorded by
Brown ; and again in 1909 by Cranston Low in Scotland, where several
cases were found by Sambon and Chalmers in 1912. Egypt lias been
known to be infected since 1847, and Sandwith has closely studied it
there. In America Gray and Taylor reported definite cases as early as
1864 f it until 1907 that the disease was generally recognized

in the United States, since which time it has been found to be widely
prevalent, especially in the Southern States, and to be an important
cause of death as well as of insanity. Much valuable work has been
done in the United States during the last few years, as recorded in the
epitome of literature in this and previous numbers of the Medical
Annual. In 1910 Sambon studied pellagra in Italy ; he collected
much evidence against the maize theor}' of causation ; and suggested
that it might be due to a protozoal parasite, and carried by the bites
of sand-flies. Recent work in America is against the sand-fly, and
more in fa\’Our of the stable-fly (Siomoxys calcitrans) as the infective
agent.

Clinical Description. — A characteristic feature of the disease is
its first appearance in the spring or summer months, and retrogression

NEW TREATMENT

4t7

PELLAGRA

in the following winter, only to recur once more the following warm
season, and in chronic cases it may thus continue for many years. On
the other hand, the disease may run an acute and fatal typhoid-like
course of only six weeks' duration, and every intermediate degree of
severity is met with. The onset is insidious, its attack is periodic, and
its course progressive (Roberts.)

Skin Lesions. — ^These are of the greatest importance, especially
from the diagnostic point of view. They commence in the form of an
erythematous red sunburnt appearance appearing on exposed parts,
especially on the dorsal surfaces. of the hands, wrists, and forearms,
and on the face. Later the condition becomes one of dry eczema,
and pigmentation ultimately results. The back and sides of the neck,
the dorsum of the feet, and the front of the chest may also become
involved. The patches are at first clearly delineated by a raised line.
There may be some burning sensation, but no pain as a rule. I.ater
the affected parts become s-wollen and tense, and even bullae may form.
After some weeks the eruption gradually subsides, leaving a rough,
pigmented thickening of the skin. In chronic cases of several years'
duration the skin may become atrophied and wrinkled. The skin over
the knees and olecranon processes may become much thickened, which
condition Roberts calls “ dermatbgra.''

Digestive Symptoms. — These include stomatitis, oesophageal
burning, pyrosis, gastralgia, belching, nausea, gastritis, enteritis,
dyspepsia ; diarrhoea is usual and constipation rare (Roberts). The
tongue is at first coated, but later becomes clean and smooth, red,
swollen, and sometimes ulcerated at the tip, as described by Sandwith.
The gums may be swollen and bleed readil3?'. The dyspeptic sjonptoms
vary very much, diarrhoea and even dysentery being the most charac-
teristic, and when these symptoms recur every spring they are of great
significance. In such cases, if no rash is present, Caszellani advises
placing the patient in the sun to see if a rash will develop.

Nervous Symptoms. — The third system to be involved is the nervous,
beginning with vertigo, irritability’ , and tremblings, and going on to
melancholia, dementia, and complete lunacy, many cases having
recently been found in asylums, the original cause of whose disorder
had not been suspected. These frequently terminate latally. Import-
ant degenerative changes in the brain and cord have been described
by American workers and by IMott in England, constituting the most
important pathological lesions found after death.

Incidence and Predisposing Causes. — The female sex is much
more affected than the male, but this is limited to early and mid-adult
life, for in children and old people there is little difference between the
two sexes. The disease is not inherited, but the incubation period is
probably short, and cases have been recorded in young infants. Any
age may be affected, but tlje great majority, especially of females, are
between twenty and forty, and the age does not influence the prog-
nosis. Occupation does not appear to affect the incidence, except in
so far as living in the country and home work predispose to the disease.

PELLAGRA

MEDICAL ANNUAL

41S

Etiology. — The cause of the disease is still unknown. The Italian
writers more especially have for long held the disease to be due to
eating maize, but they differed among themselves as to how this cereal
brought it about. Some held that it was due to living too exclusively
on a diet composed of maize, much in the same way that polished rice
causes beri-beri. Others maintained that it was only mouldy maize
which caused pellagra, either through some fungus or bacterium
in it, or through toxic products resulting from fermentative action.
Recent work by Sambon in Italy and Great Britain, and by American
workers, has thrown great doubt upon these ideas. The second theory
is that the disease is due to some unknown organism, which is trans-
mitted by the bites of insect carriers. Sambon has suggested that
the organism may be protozoal, and he suspects the sandfly to be the
carrier, but modern American work is not in favour of that insect, the
distribution and habits of which will not account for the incidence of
the disease in the Southern United States. [See abstract of litera-
ture, infra). Recent observations tend to show that the organism
may be ultra-microscopic, and that monkeys may be infected by
injecting extracts of the fresh tissues of patients who have died of
pellagra. If these experiments are confirmed, they will go far towards
proving the parasitic theory of the disease. An important Commission
is working steadily in the affected parts of the United States, and
further light may shortly be expected on the subject.

Treatment. — ^The first thing to do is to remove the patient from
the infective area. A nourishing Diet should be given, but there is
some difference of opinion as to whether maize should be forbidden.
In our present state of knowledge it would appear to be safer to do so.
Any complication, such as hook-worm disease, should be excluded.
There is no specific drug for pellagra, but there is a consensus of opinion
that Arsenic is the most valuable form of treatment. It should be
given in full doses of Fowler’s Solution, supplemented by injections of
Soamin or other such preparation. Roberts advises hypodermic
injections of Cacodylate of Soda, beginning with 3 gr. every three days,
gradually increased up to 5 gr. every two days. Salvarsan has been
warmly advocated by T. H. Martin and other American workers.
[See abstracts of literature.) Sandwith in Egypt found fresh
Bone-marrow tabloids of service. In severe cases Cole has used
Transfusions of Blood with remarkable results, as reported in the
IMedical Annual for 1913. Other treatment is of a symptomatic
character. Dilute Hydrochloric Acid and Bitter Tonics are required
to aid the w^eak digestive powers ; the occasional diarrhoea or dysentery
requires appropriate treatment ; the affected parts of the skin should
be protected from the sun by suitable Clothing, and Soothing Oint-
ments applied to inflamed areas.

Prognosis. — ^This is very uncertain, being bad in the acute typhoid
cases, but favourable in early mild attacks in w^hich the patient can be
removed from the pellagrous area. It is impossible to say if the
disease will recur in the followmg summer or not. The occurrence of

NEW TREATMENT

419

PELLAGRA

nervous symptoms is of serious significance, and when they are well
marked the prognosis is very grave. A steady gain in weight is the
most favourable sign, and much can be done by perseverance with
arsenical treatment.

Abstract of Recent Liter.\ture. — Siler and Garrison^ report on
the Thompson-McFadden Pellagra Commission, The}^^ have made an
intensive study of the epidemiology of the disease in Spartanburg
County, South Carolina, and record many interesting data. The area
is at an elevation of 700 feet, and is traversed by a network of streams.
Cotton mills support 35 per cent of the white population. Pellagra
affects 35 per thousand of the inhabitants, being markedly in excess
among the mill wllages, but density of population alone will not
explain its distribution. It is proportionally five times as frequent
in the white as in the negro population. The sex distribution shows
three times as great a prevalence among females as among males, but
this excess occurs almost entirely between the ages of twenty and
forty-four, as under ten and over fortj^-five the disease is equali^j-
prevalent among both sexes. The mortality statistics show a similar
curve. The occttpaiion also furnishes points of interest and importance
regarding the relative prevalence among field labourers, cotton-mill
workers, and those engaged in housework, as obtained from an analysis
of 234 cases. Thus 47 per cent gave housework as their exclusive
occupation, and 6 per cent more as their chief employment, while 7*7
per cent worked partly at home and the remainder of the time in the
mills. Further, of 97 females living in mill villages, nearly half did no
mill work, but housework only. The high incidence among adult
females is due to the great prevalence among household workers. The
disease was nearly seven times as prevalent in mill villages as in rural
districts : this excess was, however, not found among the miU-workers,
but among the women and children engaged during the day about the
houses. The family distribution showed an average of only 1*42 cases
of pellagra per family, while about half the total cases occurred singly
in families, and about one-fourth more were found two in a family.
Of the total number of families with pellagra, three-fourths had but
one case.

In the second part of their paper,- the same writers deal first with
the prevalence and mortality in recent years. Between 1894 to 1910
1 14 cases were traced, since which the numbers have rapidly increased
to 376 in 1912, but the death-rate has fallen from 28 in 1910 to 12 in
1912. Elaborate figures are given illustrating recurrences of the
disease. A late spring and summer retarded the recrudescence in 1912.
A large proportion of the cases were very chronic, and the disease has
gradually become milder. In 83 per cent of the patients the economic
conditions were poor, and _in 17 good. Children not infrequently
contracted pellagra during convalescence from some infectious disease.
No connection was traced between the disease and overcro’wding and
bad ventilation, the low incidence among negroes being noteworthy
in this connection. Equally unimportant was the water supply, nor

PELLAGRA

420

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did the methods of disposal of excreta, which were for the most part
primitive — the sanitary index being only 16 out of 100 for perfection —
influence the distribution of the disease. Moreover, in 98 per cent of
the cases the dwelling-houses tvere located on well-drained sites. The
diet was carefully investigated. Com-meal is the staple food, and
formed the daily or habitual diet of 84 per cent of the rural and 72 per
cent of the urban and mill-village cases. The average diet of the
poorer classes was much superior in variety and nutritive value to that
of the peasants of North Italy. Comparative studies of the diet of the
non-pellagrous population are not yet completed. The fact that two
pellagrous children had eaten no com-meal for two years before being
attacked, while several other patients had eaten very little, is against
this food being the cause of the disease.

The way in which a -widespread disease can be overlooked until
attention is prominently drawn to it is remarkably exemplified by the
history of pellagra in America. It was only in 1909 that the disease
was first recognized in the State of Illinois ; yet a recent Commission
found no less than 500 cases there, while many more must exist.
O. S. Ormsby^ records an interesting account of their investigations.
A good clinical description of the cutaneous, alimentary, and nervous
symptoms is given. The influence of sunlight in determining the
localization of the skin lesions was demonstrated by the use of fenes-
trated gloves by suspected patients, when the eruption was largely
limited to the exposed parts. Diffuse light without actual exposure
to the sun may be effective. Denuded and superficially ulcerated
tongue, and diarrhoea, especially severe in fatal cases, were present in
a very large proportion of the cases, together with mucus and putre-
factive changes in the stools. The skin lesions presented an angio-
neurotic process, apparently due to an irritant toxin. The change in
the cen-tral nervous system was a central neuritis without any infiltra-
tion of perivascular sheaths. The liver also showed fatty degeneration
due to toxins. The blood showed a reduction in the polynuclear and
large mononuclear leucocytes and an increase of the lymphocytes,
but no organisms microscopically or on culture. The complement
fixation test gave doubtful results. In one cottage 59 healthy people
were fed on a diet in which com predominated, for: a year, and in another
house 58 received no corn, but a nearly equal number of cases of
pellagra occurred in each, while many feeding experiments on animals
also gave negative results. Fungi and bacteria from com failed to
infect animals. Entamoebae w^ere commonly found in the loose stools,
but do not appear to be a cause of the disease. Analyses of the diets,
of various institutions showed no marked deficiencies. An entomo-
logist investigated the simulia, but little support was obtained for that
theory, the Simiilium reptans, which Sambon incriminates, being
absent from North America except in Greenland ; and they point out
that Sambon formulated his h^'pothesis and named the carrier before
entering on his investigations. The Commission concluded that pellagra
is probably due to some unkno\m micro-organism.

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421

PELLAGRA

E. H. Cohoon and F. J. Famell^ record a careful study of 17 cases in
Rhode Island institutions. There was commonly evidence of peripheral
pol5?iieuritis, often with loss of knee-jerks, and the small mononuclear
leucocytes were increased. The spinal fluid obtained by lumbar
puncture showed a few lymphocytes, indicating a chronic inflammatory
process, while a central neuritis is a marked feature.

A. H. Jennings and W. V. King* have made an intensive study of
insects as a possible etiologica,! factor in pellagra in conjunction with the
Thompson-McFadden Commission. They lay stress on the disease
being rural and affecting household workers especially. Ticks they
found to be very rare, and since they more frequently attack men,
they are excluded by the far greater prevalence of pellagra in women.
Lice were so rarely met with as to be quite inadequate as carriers of the
disease. The bed-bug was of nearly universal occurrence, and would
not explain the sex incidence. Cockroaches rarely attack man ;
iabanidcB, including horse-flies, were also rare. Fleas w'ere carefully
studied, but as far as attacks on man are concerned were found to be
almost of negligible importance, especially in the districts most affected
by pellagra. Culicidcs were comparatively few in the Spartanburg
country as compared with other areas showing few or no cases of
pellagra, nor will mosquito infection explain the preponderance of the
disease among females. SimulidcB, which Sambon suggested might
be the carriers of pellagra in Italy, have been carefully studied, and
are numerous in the many streams of the district, usually within about
two hundred yards of the houses, both those with and those without
pellagra cases. They were found to be essentially wild in their habits
and rarely bite man, while their life is short, and it is very unlikely that
they would often bite a second human being at a sufhcient interval
to allow of the development of a parasite within them and its trans-
mission through their bites. Even when these gnats were breeding in
villages, they showed not the slightest disposition to seek out. and
attack man or to come about his dwellings. jMoreover, the Commission
have information that pellagra occurs in Barbadoes, although no
species of simulium has been found in the island, the physical characters
of which entirely preclude the existence of the fly there. They conclude
that, apart from Sambon ’s theory, these flies could hardly have
attracted any suspicion of connection with pellagra in the United
States. On the other hand, Stomoxys calcitrans, the biting stable-fly,
appears to be the most likely carrier. Although it feeds by preference
on animals, yet man is very frequently attacked by it ; though most
abundant in rural areas, it is usually common in towns and cities, as it
breeds in stable manure ; it 'wanders far from its breeding-grounds, and
may be dispersed by trains and steamers ; it utilizes several hosts for
a single meal; it frequently visits human dwellings, and has a
preference for living rooms; while, lastly, it bites during the day,
and so accounts satisfactorily for the excessive infection of women
engaged in household Avork.

S. R. Roberts® discusses the analogies between pellagra and other

PELLAGRA

422

MEDICAL ANNUAL

mosquito-borne diseases, and thinks these insects are probably the
carriers of the infection.

W. H. Harris" records and illustrates the production of pellagra-like
skin lesions on the face and hands of monkeys by a Berkefeld filtrate
of extracts of human tissues of cases recently dead of pellagra, and
supports the parasitic view of the origin of the disease.

Cases of Pellagra in Great Britain. — L. W. Sambon and A. U.
Chalmers 8 discuss the prevalence of pellagra in the British Isles, and
refer to cases which they consider to be this disease in medical
literature back to 1866. The writers have visited the eastern districts
of Scotland in search of the disease, and maintain that pellagra is
certainly endemic in Fifeshire, Forfarshire, Aberdeenshire, and the
Shetland Isles. Two cases seen in Scotland are described, Charles R.
Box^ has recorded two fatal cases of pellagra in English boys. One of
these was under his care at St. Thomases Hospital, and ran an acute
course, and the other \vas ill for several years, but the true nature of
the disease was not recognized at the time. Both came from Slough,
in Middlesex. Maize could not have been the cause.

F. W. Mott^*^ describes in detail and illustrates the histological
changes found in the nervous system in Box’s fatal case, as well as
those found in an Egyptian case. There was an entire absence of any
evidence of meningeal or perivascular infiltration with lymphocytes or
plasma cells, or with polynuclear leucocytes, such as is so characteristic
of protozoal disease. This is against the protozoal theory of the
origin of pellagra, although it does not disprove it. Slight degeneration
of a few fibres of the sciatic nerves and cauda equina was found. The
spinal cord showed slight diffuse sclerosis, affecting especially the
direct and crossed pyramidal tracts, Gowers’ tracts, and Goll’s column.
In the central nervous system, degenerative changes were met with in
the posterior spinal ganglion cells, anterior horn cells, in those of
Clarke’s column, the Purkinje cells of the cerebellum, and in the
pyramidal and Betz cells of the cortex. The changes were similar in
the English and Egyptian cases.

L. W. Sambon^^ records two further cases of pellagra met with in
England, one at Slough, and one at Lymington, in the New Forest,
where he found two varieties of simulitmi. He also further discusses
the incidence of the disease in Itaty. He found that, contrary to
experience elsewhere, on the island of Burano, near Venice, the disease
is only met with in adult male fishermen, who work along the mainland
coast where swarms of small biting flies occur. Both the infected and
uninfected classes eat the same maize. He sees no reason for incrim-
inating either the stable -fly {Stomoxys calciivans) or mosquitoes, as
suggested by \vorkers in the United States. In a further paper,
Sambon reports three more cases in Great Britain, in Cardiganshire,
Shropshire, and Napsbury Asylum respectively^ and in a yet later
paper records several more.^^ G. S. Blandy^^ records in detail the
Napsbury case, and also reports two more seen by him in the Prestwich
Asylum, Manchester. J. W. E. Cole^® also records one in the Bethnall

NEW TREATMENT

423

PELLAGRA

House Asylum. It is already quite clear that the disease is widely
prevalent in England, and has for long been o-verlooked, just as it was
in the United States. Further inquiries into its exact prevalence will
be awaited with interest,

H. P. Mills^® has specially studied the pathology of the gastro-
intestinal tract in pellagra, and found a chronic catarrhal inflammation,
sometimes amounting to a haemorrhagic colitis. He thinks this is
secondary, and produced by toxic products of unknown origin.

H. Raubitschek^’ records numerous unsuccessful attempts to cultivate
organisms from the blood of pellagra patients, while serological methods
proved useless in diagnosing the disease.

R. M. Grimm^s discusses the etiology of pellagra in 323 cases seen by
him during two years in the United States. The disease was most
prevalent among whites and in the female sex, and between twenty
and forty years of age. Most cases had their onset in the months of
May and June, and among the poorer classes and in the vicinity of
former cases, but heredity did not play any part in its causation. He
also came to the conclusion that the food acted as a contributory and
probably as an exciting cause.

Victor C. Myers and Morris S. Fine’® report on the metabolism in
pellagra. They found foodstuffs to be well utilized, but a lowered
physiological efficiency and anacidity. There was marked indicanuria
and excess of indol and skatol, and a high elimination of ethereal
sulphates, pointing to bacterial putrefaction high up in the intestine.

W. J. MacneaP® deals with the intestinal bacteria met \^dth in pellagra,
and found the flora departed considerably from the normal. In acute
cases with diarrhoea, the Gram-positive cocci were more, and the gram
negative bacilli less, numerous than normal. He isolated three
organisms which gave agglutinating reactions with the bloods of
pellagra cases, but also with some normal bloods, so that the results
of their investigation so far are only suggestive, and further inquiries
will be made on similar lines.

Treatment. — E. H. Martin-^ writes on the relative value of Sodium
Arsanilate and Salvarsan, based on 83 cases carefully analyzed, but only
38 were long enough under observation to draw reliable conclusions
from. Of II cases treated wdth the former drug, 9 recovered and
2 died, while of 27 under salvarsan, 20 showed apparent cures, 3
improved, and 4 died. From five to twelve doses were given, usually
at intervals of seven to ten days, beginning with 0*2 gram, then 0*4,
and increasing to o*i gram for every tvrenty pounds weight of the
patient. He urges that very many patients now allowed to sink
gradually without any radical treatment, can be saved by salvarsan
injections.

G. M. Nileses advocates the use of Hydrotherapy in the treatment.

References. — ^Amer. Jour. Med. Sci. 1913. ii, 42; 238; ^Jour,

Cutan. Dis. 1912, 589 ; ^Bost. Med. and Surg. Jour. 1913, i. 50 ; ^Ibid. 411 ;
^Ibid. 233 ; ’^Jour. Amer. Med. Assoc. 1913, i, 1948 ; ^Brii. Med. Jour. 1912,
ii? 1093 ; ^Brit. Med. Jo%ir. 1913, ii, 19; ^^Ibid.] ^Ubid.; ^-Ibid. iigj

PELLAGRA

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^^Ibid. 297 ; ^^Lancet, 1913, ii> 713 ; 717 ; ^^Jour, Amer. Med. Assoc.

IQ13, i, 88g ; ^"^Detit. med. Woch. 1912, 2169 ; "^^Jour. Amer. Med. Assoc.
1913, i, 1423 ; ^^Amer. Jour. Med. Sci. 1913, i, 705 ; ^^Ibid, 801 ; ^W.Y.

Med. Jour. 1913, i, 547 ; ^^Amer. Jour. Med. Sci. 1913, ii, 230.

Beverley R. Tucker, M.D., Richmond, Virginia.

Etiology. — Pellagra, which has been known in Italy since 1728,
and has since been observed in all the countries of Southern Europe,
in Asia Minor, Northern Africa, the West Indies, Central America,
the United States, and other places, has become a disease of such great
importance that it deserves the special consideration of the medical
profession the world over. At the present time, it is estimated that
there are more than 15,000 cases in Italy and as many as 15,000 in
the United States. Its recent occurrence in the United States as far
north as New England in the eastern part, and Peoria, 111., in the
central western part, and in England, takes it out of the class of those
diseases confined to tropical and semi-tropical countries. More or
less coincident with the appearance of pellagra in Italy w^as the use of
corn meal as a food among the poorer classes, and the general impression
gained ground that pellagra was a toxaemia originating from spoiled
maize.

When, in 1907, eighty-eight cases of pellagra were reported in the
United States by Searcy, from the Alabama Insane Asylum, it was
supposed that pellagra occurred only among the poorer classes, but
since then many cases have been reported among those whose hygienic
and social surroundings were good.

Thanks chiefly to reports from Italy and the advocacy of Lombroso,
when the disease first appeared in the United States the maize theory
of causation w^as generally accepted, but since then it has been largely
discarded. People who have never eaten corn products in any form
have had the disease, which also occurs in localities where corn is neither
raised nor imported. Further, those vrho have been known to eat
fermented or spoiled coin meal for long periods of time have failed to
contract the disease. During the Civil War in the United States, the
Confederate soldiers ate com meal, which was often spoiled, as their
chief article of diet, and careful enquiry fails to Show that the disease
was present among these soldiers. It is improper, therefore, fiom a
commercial and economic standpoint, as well as unscientific, to con-
demn this great staple article of food. Various bacteria, fungi, insects,
and toxins have been thought to be the cause of pellagra, but it has
not been proved that the disease originated from any of these sources,
nor has there been an}’- proof that food, water, or air is the carr^dng
agent. , By some the disease has been considered a place infection, but
so many cases have occurred singly in a locality that this can hardly be
true. Sunlight has been supposed to have a causative relation, but
it has been observed that patients may have an increase in their
symptoms or a recurrence during the sultry warm days of winter or
from sitting by a fiie. Heat, and possibly light, may aggravate the
condition, but they certainly have nothing to do with the cause.

PLA TE XXXII,

PELLAGRA: CASES AS SEEN IN AMERICA

BY DR. BEVERLEY R. TUCKER

[It has been found difficult to obtain illustrations of this complaint, and the Editors are greatly
indebted to Dr. IjEveri.ev Tucker for the tinted photographs, which it is belie\-ed fairh’ represent
the cases, although not taken under ideal conditions.]

This patient is a man ^\ho had a .se\ere attack of pellagra during the mu:
t into complete remission in about two months. He has nut i.ome under
:e lesions on hands, lower part of forearms, forehead, side of the nose.

PLATE XXX in.

P E L L A G R A — contiuued.

Photograph of a fatal case, showing marked lesions on the hands and around the mouth.

PJiotooraJ>h fiy Di\ Btxy?-lty K. Tift

ME Die A L A .ViV UA L, igr^.

NEW TREATMENT

425

PELLAORA

No age is exempt from pellagra, although it is most common
between the third and fourth decades of life. Its onset is most frequent
in the spring, but it may make its appearance at any season. The
cases run a course of a few weeks to a few 'months, either to death or
remission. Those who survive the first attack usually have a recurrence
the following spring. In some cases amelioration and recrudescence
follow each other every few months. The disease is not considered
contagious. As far as the writer has been able to learn, no physician,
nurse, or attendant has ever contracted the disease from association
with patients.

In view of the foregoing observations, we are brought face to face .
with a great disease problem. Those who speak dogmatically about
the origin of pellagra show ignorance in so doing. The true cause is
absolutely unkno’v^^l. A few facts in this relation, however, seem to
be more or less definitely established. It has been the observation of
the writer and others of large experience with the disease that it
nearly always occurs in debilitated people, and it frequently follows
in the wake of such conditions as syphilis, emaciation, alcohoHsni,
morphinism, and tuberculosis. The writer cannot recall having
observed the onset of pellagra in a patient who was robust immediately
preceding the appearance of symptoms. It has been suggested by
Babcock that a monotonous diet, such as is used in charity institutions
and rural districts, has some relation to pellagra. Whether this is
simply because of malnutrition or because of an analogy to sprue,
scurvy, or beri-beri, is unknown. The author, however, is inclined to
the former view.

To suggest a field for research, it has recently occurred to the writer
that the disease may be oral in its primary location. In looking back
o^^er his cases, the majority of them give a history of having started
with stomatitis, and oral inspection reveals inflamed gums, tongue, and
buccal mucous membrane, usually with marked pyorrhoea. It may
be that, as in diphtheria or syphilis, there is a focal infection, the focus
in this instance being in the mouth, and later, constitutional symptoms
become manifest. As far as the wTiter knows, no special bacteriological
investigation has been made of the oral cavity in pellagra.

Symptoms. — These may be divided so as to fall under four general
headings : gastro-intestinal, cutaneous, nervous, and mental.

The gastro-intestinal tract is inflamed in its whole extent, .the mouth
being red and sore, usually with considerable salivation. The stomach
is inflamed, and there is generally nausea and vomiting. The intestines
are also inflamed, which causes, as a rule, severe and sometimes
intractable diarrhoea, although some patients have no diarrhoea.
There is one thing of great importance about this set of symptoms : it
lias recently been shown by the writer in the study of the disease in
its incipiency that these symptoms of the mouth, stomach, and
intestines are usually the first to appear, and they were recorded as
primary symptoms in ninety out of one hundred cases.

A few clays or a few months after these symptoms, there appears.

PELLAGRA

426

MEDICAL ANNUAL

always on the dorsal surface of the hands and often on the extensor
surface, forearms, forehead, alae nasi, neck, and dorsal surfaces of the
feet, an eruption, which is usually red at first and resembles sunburn. It
soon becomes dark and rough. Thickening and pufhness of the skin
may develop, areas of skin may slough off, and large cracks or fissures
occur. Itching and burning are not prominent symptoms. As the
skin eruption gets well, desquamation takes place. The hand lesion
tends to extend around the wrist in an annular fashion, while the line
of demarcation is quite distinct on the wrist or forearm. The lesions
are always symmetrical. During the interval between the attacks
the skin looks either normal, or smooth and glistening. (See Plates
XXXII, XXXIII, XXXIV, XXXV).

The nervous symptoms consist of insomnia, anxiety, giddiness, and
sometimes ataxia, change in reflexes and partial paralysis, and, as a
rule, follow or are coincident with the cutaneous symptoms.

In regard to the mental symptoms, the patients may or may not
become absolutely insane. When they do, the insanity follows no
known type of mental disease. Patients often have delusions and
hallucinations. They not infrequently commit suicide, and drowning
seems to be the favourite mode. Nearly constant mental symptoms
are depression and apprehension.

Neither stomach, fcocal, blood, nor urinary examinations have thrown
much light upon the vStudy of pellagra. Hydrochloric acid is often
absent from the gastric juice, but this is not constant. Amoebae are
frequently found in the stools, but this is common to other conditions.
A moderate and sometimes severe secondary anaemia is usually present.
Wassermann reactions are uniformly negative, except in those cases
complicated with syphilis. Nothing has been gained by examination
of the cerebrospinal fluid.

Diagnosis. — Pellagra without cutaneous lesions can hardly be
diagnosed, because diarrhoea with nervous and mental symptoms is
common, especially in institutions. The area of distribution of the
skin lesions, and especially the fact that those of the hand end in a
distinct line of demarcation, are of great diagnostic importance. Losses
of weight, insomnia, apprehension, vertigo, and symmetrical cutaneous
lesions are practically constant manifestations.

Course. — ^As the disease progresses in the cases in which remission
does not take place, the patient goes on to a death which presents a
horrible picture. The patient is weak and emaciated. The cutaneous
lesions, although not very painful, are distressing in appearance.
Stomatitis, gastritis, diarrhoea, and proctitis are usually pronounced.
Salivation is often profuse. It may be impossible for food to be
retained. The patient frequently is more or less comatose, and when
aroused, the mind is disturbed by marked hallucinations and delusions.
Life may last for days in this distressing state, until death comes as a
decided relief.

Prognosis. — This depends upon whether the case goes into a
remission or not. About 50 per cent die in the first attack, which

PLATE XXXIV.

P E L L A G R A — contimted.

The hand of a Pellagrin. Note the areas nf .sloughing, and the deep fissure between
the inde.\ and middle lingers.

riudo^i'a^h hy Pr. K. /’.vr/iw.

MEDICAL ANNUAL. 1914

■continued.

of a hand of a case durint^ reniKsion. This patient had se\ere lesions ; but
a ^ligKt roughness is left.

Phofo^?-txjfh bv Dr. Bcz't'fitV /V. Tuck

^•UAL, igi4.

NEW TREATMENT

427

PEMPHIGUS

may last from a few weeks to a few months ; while the others go into
a remission, usually during the winter, and may die in from the second
to the tenth attack, or may recover entirely. The writer has dases
which have remained well since 1909 and igio, and believes the
prognosis may be bettered by the urotropin treatment combined with
proper hygiene.

Treatment. — ^We have no specific for pellagra. Iron, Mercury, and
Arsenic have been of benefit to some cases. Arsenic seems to be most
effective when given hypodermically, either in the form of atoxyl or
cacociylate of soda. Some cases have been reported as much improved
by salvarsan. Several years ago the writer introduced the use of
Urotropin in pellagra, and considerable experience has confirmed him
in the belief that this is the most valuable remedy thus far known.
It is administered in 10 or 15 gr. doses in a glass of water every four
hours. It seems to act better ^vhen some alkali, as for instance
half a drachm of bicarbonate of soda, is given with each dose. In a
few cases the kidneys are irritated and hsematuria may be noted.
When this occurs, the drug has to be discontinued. Hexamethylena-
mine, or urotropin, splits into ammonia and formaldehyde, and
formaldehyde may be found shortly after its administration in the
saliva, sweat, blood, urine, and cerebrospinal fluid. The benefit is
derived probably from the antiseptic properties of the formaldehyde.
The majority of cases put upon this treatment begin to show improve-
ment in all their symptoms in about three days, and go into remission
within three weeks. The earlier the urotropin is administered, the
more beneficial are its effects.

In addition to drug treatment, general hygienic measures should be
used. Good, nourishing food should be pushed as far as possible,
seeing that the diet is varied. Local treatment to the cutaneous
lesions seems to have but little effect, and it has been the habit of the
writer and other workers in this field to rely rather upon systemic
measures.

Possibly no disease offers so wide a field for research as pellagra ;
and the internist, the neurologist, the alienist, the dermatologist, the
pathologist, and the hygienist may all be equally interested. It seems
improbable, however, that the disease will be thoroughly understood
until it is studied by competent commissions giving their entire time
to the solution of its problems.

PEMPHIGUS. E. Graham Little, M.D., F.R.C,P,

Custance^ reports an acute case in a man aged 19, clinically typical,
in which a diplococcus was isolated from the blood and sputum. A
Vaccine prepared from this organism vras injected, in doses increased
from 5 to 500 millions, and at intervals of three to six days, and though
the case was exceptionally severe, improvement was rapidly obvious
under this treatment, and recovery took place. The patient
incidentally gave a positive Wassermann reaction, which is explained
as probably due to congenital syphilis. The introduction of the

PEMPHIGUS 42S MEDICAL ANNUAL

diplococcus seems to have been effected by a tattooing, which resulted
in an acute septic ulcer.

Leszczynski^ recommends intravenous injections of Quinine, accord-
ing to this formula : —

Bf Quinin. Hydrochlor. i | Aq. Destillat. 200 parts

Sod. Chlorat. pur. 1*70 |

Of this solution, 100 c.c. injected wdth 50 c.c. of 8*5 per cent saline
solution was the initial dose ; this would be doubled in later injec-
tions, of which as many as fourteen were given in one case. Relief of
itching was notable after the first.

Pemphigus Foliaceus. — Kessler^ has a careful study of tw’-o cases.
The first was in a Danish woman, aged 56, in whom the disease
began in June, 1911, with a blister on the cheek. The disease spread
slowly but steadily until, by March, 1912, the entire body was covered
with blisters. Nikolsky's sign — ^the separation of the superficial layer
of the epidermis by trauma — was very marked. The temperature
ranged from 98° to 104°. The exfoliation of the skin was general and
abundant. She was given lo-gr. doses of Quinine every four hours
for several weeks, without an3’' untoward symptoms. Bran Baths'
w’ere given daily. She appeared to recover completely, and was
dismissed from hospital after six months’ detention, but six months
later had a relapse.

The second patient was a white lad, aged 16. The disease had
commenced with a single lesion on the arm, and had spread to cover
the whole bod}’, except the conjunctivse and mucous membranes.
This patient lost his finger- and toe-nails. He was given Quinine in
large doses, 4 to 7 gr., 4-hourly, and Linseed Baths with J oz. compound
solution of Cresol to the bath, and cold cream was applied to the joints.
He left hospital twelve weeks later, apparently well.

In the discussion supervening on this paper, Sutton reported a case
in which pure cultures were obtained of B, pyocyancus which has been
frequently associated vdth this disease, and the patient recovered
almost completely within nine weeks, apparently as a result of treat-
ment with autogenous Vaccines. At this stage a single dose of
Salvarsan appears to have completely cleared the skin, and to have
benefited the patient so remarkably that he put on 40 lb. in weight
in two months. Other speakers had tried salvarsan without much
benefit.

References. — '^Pract. 1913, ii, 710; h 4 rch. f. Derm, u. Syph. 1912, Oct.
(Brit. Jour. Derm, xxiv, 447) ; ^Jour. Amer. Med. Assoc. 1913, ii, 102.

PENIS, SURGERY OF. Priestley Leech, M.D., F.R.C.S,

Babler^ reports a case of primary tuberculosis of the glans penis in an
otherwise healthy man, aged 72. It consisted of a hard nodule larger
than a filbert, midway between the corona and the meatus. Naturally,
malignant disease was thought of, but examination after removal
showed that it was tuberculous.

Gerster and Mandelbaum^ report the formation of hone in the human

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PERICARDITIS

penis. This is a very rare condition. The patient was a man, 49
years old. The bone was oblong, lamella-shaped, 3*5 cm. long and
1*75 cm. broad, situated just where the penis emerges from under the
S3miphysis. It was excised ; histological examination proved it to
be bone.

References. — ^Ann. Suyg. 1913 , i, 894 ; Hbid, 896 .

PERICARDITIS. {See also Rheumatism in Childhood.)

Carey Coombs, M.D., M.R.C.F.

■ A rare cause of pericarditis, gonococcal injection, was lesponsible for
the case of effusion described by Robin and Fiessinger.^ The fluid was
highly fibrinous recovery followed puncture through Marfan’s point
{vide infra). Though the organisms were not found in the fluid,
its gonococcal origin was indubitable, for the patient had urethritis
with gonococci in the discharge, polyarthritis, and enlargement of the
spleen.

Fromberg 2 reports a case of some interest in that the pericardial sac
contained fluid charged with tubercle bacilli, but without the usual
' histological features of tuberculosis in its inflamed walls.

Essex Wynter^ once more calls attention to absence of abdominal
respiratory movement as an indication of pericarditis. He points out
that a knowledge of this fact has very considerable diagnostic import :
on the one hand, it may lead to an early discovery of the perieardial
lesion, while on the other it may prevent a fruitless laparotomy in
search of an inflammatory cause for the abdominal rigidity. It is a
reflex immobilization of the diaphragm that is responsible for the loss
of abdominal movement, as radiographic examinations demonstrate.

Wynter believes in the Salicylate treatment of rheumatic pericarditis,
but thinks that internal administration alone is inadequate ; he
supplements it by daily applications of an ointment, containing methyl
salicylate 2 dr. in lanolin i oz., to the praecordium, renewing it daily
for four or five days.

Cardiolysis. — ^Dunn and Summers^ performed this operation to
relieve a patient with mediastinopericarditis ; the subsequent history
is not long or explicit enough to show whether the expected benefit was
realized. Portions of the second to sbith left ribs with their costal
cartilages were resected flush v.dth the sternal margin. In Simon’s®
case, the adhesions were possibly due to rheumatic carditis ; temporary
improvement followed an operation consisting of resection of ribs and
break ing-down of adhesions, but the boy died within twelve months,
of cardiac failure. The first-named authors say that cardiolysis is
not to be expected to relieve a heart enmeshed in pericardial adhesions
if these are due to polyserositis or to tuberculosis, or if the heart itself
is diseased ; the indications for this operation are therefore very
restricted, unless it is frankly undertaken to give more space to an
. enlarged heart rather than to liberate it from adhesions.

Drainage of Pericardial Effusions. — In a careful and exhaustive
monograph, Blechmann® considers the whole subject of pericardial

PERICARDITIS

430

MEDICAL ANNUAL

efifiision, but with especial reference to diagnosis and treatment.
Serous and haemorrhagic collections are curable, he thinks, by simple
paracentesis, though sometimes those which are provoked by tuber-
culosis of the sac call for pericardiotomy without subsequent drainage.
Purulent exudation, on the other hand, always requires drainage after
free opening — the nature of the fluid can, of course, be ascertained only
by exploratory puncture. Blechmann considers the various methods
in use, and condemns those that attack the sac through the anterior
chest wall, since they introduce dangers (puncture of pleura and heart,
wounding of mammary vessels) without any compensating advantages.
Indeed, the method which he extols, that of Marfan, claims as its
advantages, not merely the negative one of avoiding dangers, but
also the positive one of finding the fluid. He shows that the heart lies
in front of and slightly above the effusion, so that this should be
approached from below, a line of attack that is profitable for purposes
of drainage, since it enlists the force of gravity on its side. The actual
path of approach traverses the skin at the tip’ of the xiphisternum,
and passes upwards behind the latter through the diaphragm into the
pericardium, avoiding the peritoneum. The patient half lies down on
liis back ; and local anaesthesia may be used. The tip of the index
finger of the operator’s left hand rests on the tip of the xiphisternum
as a guide, and the needle (a small Potain trocar or a lumbar-puncture
needle) is introduced through the middle line immediate^ below the
tip of the xiphisternum ; it is then passed directly upwards for a distance
of 2 cm., hugging the posterior deep surface of the xiphisternum. The
point of the needle should next be directed slightly backwards and still
upwards, to reach the pericardial sac. He recommends a similar route
for incision of the pericardium, where this is indicated, an operation
advocated in this country by Ogle and Allingham, the actual line of
incision corresponding with the left costal border. These procedures
have given satisfactory results in the hands of various operators,
though experiences hitherto published are of necessity few in number.

References. — "^Lancet, 1913, i, 768; ^ Deiit. med, Wock. 1913, 1539;

^Clin. Jour. 1913, 185 ; ^Amer. Jour. Med. Sci. 1913, i, 74 ; ^Brit, Med. Jour.
1912, ii, 1649 and 1913, i, 1050 ; ®Paris, Bailliere et Fils, 1913.

FERICOIilG MEMBRANES. Sir Berheley Moynihan, M.S., F.R,C.S.

Harold Upcott, F.R.C.S.

Since he drew attention to this condition in 1908, Jackson has observed
and operated upon numerous cases. ^ He emphasizes the fact that
this membrane in no way agrees with the ordinary conception of an
adhesion. He considers the various theories which have been put
forward to explain the cause or origin of membranous pericolitis, and
expresses his own view that all cases have not the same etiology.
Some cases support the view of Keiller and Cotte, that the membrane
represents the prolongation of the omental attachment along the
anterior muscle band of the ascending colon. Most cases, however,
suggest that the membranous structure is peritoneum loosened from
its close connection with the abdominal wall and colonic surface by

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431

PERfCOLIC MEMBRANES

some serous exudate, after which the vascularization and connective-
tissue banding has occurred as a chronic reaction to irritation (Hall).

The principal symptoms are pain, of varying intensity, diffused over
the right side of the abdomen, and often of abrupt onset; diffuse
tenderness of right side of abdomen, or even hyperaesthesia, but with-
out muscular rigidity, points of greater tenderness being frequently
found low dowm in the groin, at McBumey’s point, or just beneath the
costal margin ; marked constipation, which may be relieved for a time
by free purgation ; overfilling of the caecum with gas, often causing
great distress ; and mucous diarrhoea, which may alternate with the
constipation. Gastric disturbances, loss of weight, and neurasthenic
symptoms complete tire list.

The surgical treatment should, in the majority of cases, comprehend
the removal of the obstructing pericolic membrane, supplemented by
caecal plication. In more advanced cases, some form of plastic anasto-
mosis or short-circuiting may be necessary.

From a study of twenty-nine instances where he has met with some
form of pericolic membrane at operation, Flint® thinks they may
roughly be divided, according to their distribution, into three gi'oups.
The commonest is that where the membrane extends from the parietal
peritoneum along the lateral margin of the colon, particularly near the
hepatic flexure, over into the lateral and ventral aspects of the colon
and caecum.

Another type occurs lower down, the membrane passing over into
the head of the caecum, and usually covering the proximal half and,
more rarely, the entire appendix. The third and rarest type of veil
extends from the ventral aspect of the colon, and passes inwards to
become continuous with the omentum. It often holds the ascending
and first part of the transverse colon side by side, with a sharp angula-
tion at the hepatic flexure.

From dissection of a series of human embryos and two infants at
full term, Flint has found conditions which show clearly that these veils
are embryonic and normal structures. After rotation of the gut, the
caecum becomes attached to the peritoneum of the posterior abdominal
wall just beneath the liver.

In some instances these secondary attachments are more extensive
than in others, and during the subsequent descent of the caecum they
become drawn out into the membranous veils described by Jackson.
Flint thinks it is certain that they are not the products of inflammation
or the residue of repeated attacks of colitis.

While generally speaking these membranes are not, responsible for
any symptoms, there can be no doubt that in certain cases they
interfere with the mechanical functions of the colon, and give rise to
attacks of pain and distress in the right side of the abdomen. Embry-
onic veils which embrace the appendix, kink it, and are probably
responsible for many of the cases of chronic appendicitis in which
they occur. They are to be clearly distinguished from adhesions
about the appendix resulting from previous infections.

PERICOLIC MEMBRANES

432

MEDICAL ANNUAL

Where the membranes are causing any hindrance to the propulsive
functions of the colon, they may be incised ; this is all that is required.
After dividing them, and also Lane's ileal band, Flint trusts to the
post -operative distention of the gut to prevent their re-formation.

References. — K4mt. Suvg. 1913, i, 374 ; ^Johns Hop. Hosp. Bull. 1912, 392.

PERITONITIS. Sir Berkeley Moynihan, M.S., F.R.C.S.

Harold Upcott, F.R.C.S.

A useful study of peritoneal adhesions has been carried out by Adams, ^
who found that the only reliable method of inducing non-inf ective
adhesions was by introduction of sterile foreign bodies. Chemical
irritants were much less rehable, and the effects of scarlet red were
negative. Merely rubbing the peritoneal surfaces with sterilized gauze
could not be depended on to ensure the formation of permanent
adhesions.

In his investigations, Adams was naturally led to study the functions
of the omentum, and he considers that it plays an important part in
the restoration of damaged peritoneal surfaces. It becomes adherent
to any bare area within the field of its excursion, and supplies numei'ous
endothehal and connective-tissue-cells to the denuded surface. Unless
the omentum itself becomes fibrotic, such adhesion persists only until
the damaged area is healed. He thinks that this function of the
omentum should be utilized by the surgeon to prevent the formation
of post-operative sterile adhesions by the application of omental grafts
over any areas that have been stripped of peritoneum. The use of
lubricants, such as oil or vaseline, appears to be valueless.

When the surgeon desires to promote the formation of adhesions, a
foreign body, such as a piece of sterilized gauze, should be fixed in
position until the second or third day, by which time fibroblasts will
have appeared in the inflammatory tissue.

Danielsen^ reports a case which presented the symptoms of perito-
nitis attributed to appendicitis. On opening the abdomen, a quantity
of pus was found among the intestines, having the odour commonly
associated with a perforated appendix. The appendix, however,
showed no evidence of disease. While wiping the pus out of the
pelvis he observed a segment of a tape-worm adhering to the gauze.
Further portions of the parasite were then removed. On examining
the intestine, he found a perforation in the ileum about twenty inches
above the ileo-csecal valve, the serosa surrounding it being inflamed
and purulent. This segment was resected and the ends were
anastomosed. Further search discovered the head of the worm among
the fimbrim of the right Fallopian tube. A small ovarian C3?-st was
also present, showing on its surface an inflamed granulating area ;
this was resected, with the tube, which still contained the head
of the worm.

He thinks that the perforation was not caused by the worm, but
that a purulent salpingitis led to adhesions betw^een the intestine and
the fimbriated end of the tube. An abscess formed among the

NEW TREATMENT

433

PERTUSSIS

adhesions and discharged into the intestine. The free drainage thus
established allowed the salpingitis to heal, but the end of the parasite
escaped through the perforation, and by its movements loosened the
adhesions, thus allowung the escape of intestinal contents into the
peritoneal cavitj^

References. — ^Lancet, 1913, i, 663; -MiincJi. msd. Woch. 1913, 41 1.

PERTUSSIS, Frederick Lanpnead, M.D., F.R.C.P,

Treatment. — Fletcher’- has obtained some success with Adrenalin.
He has used it in forty cases in doses varying from i to 3 min. of a
i-iooo solution given every three or four hours by the mouth. There
was decided benefit in practically every one. It was exceptional under
this treatment for the attack to last for more than three weeks. In his
experience adrenalin checks the vomiting quickly, thus producing
marked improvement in the patient’s general condition before the
cough has ceased. Lord^ records another case which benefited under
the same treatment.

The discovery in 1905 by Bordet and Gengou of a bacillus which they
regard as the cause of the disease has led to the employment of Yaccines.
These writers describe the bacillus as a little ovoid micro-organism,
resembling that of Pfeiffer, somewhat elongated at times, but frequently
so short as to appear like a micrococcus. As Scott® points out, the
principal argument in favour of this organism being the cause appears
to be furnished by a study of the specific properties of the serum. The
sera of children who have never had whooping-cough, or have had it a
long time before, does not agglutinate the bacillus, whilst the sera of
children who have recently suffered have a moderate and constant
agglutinating power. Twenty children injected with Bordet’s pertussis
vaccine developed a severe negative phase. Ivlimenco and Fraenkel
were able to produce apparently typical whooping-cough by injecting
the bacillus into monkeys. This organism is found in the early stage
of the disease, in the expectoration which comes from the depths of the
bronchi, after a paroxysm. Such a sputum contains it in considerable
numbers, and in favourable cases gives an almost pure culture. Ladd,
of Boston, has prepared a vaccine of the organisms grown on blood-
agar and killed by heating in a water-bath at 60® C. for one hour. He
reports no ill-effects from its use, even in doses of 40,000,000 bacteria,
in nine cases. Graham records twenty-four cases whom he injected
with 40,000,000 bacteria every three days. The number of paroxysms
became less, their severity diminished, cyanosis was less marked, and
the vomiting decreased. Seven were probably not benefited. Scott’s
own patients number seventeen. He regards fourteen as being cured
by the vaccine, and the remaining three as improved. He injected
the vaccine into the buttock. In his opinion, stronger doses should
be given in the early stages. Wilson^ has used it in twenty-four
cases, and concludes that it rapidly controls the spasms, that the
improvement is somewhat proportionate, to the systemic reaction,
and that when this is very feeble it should be excited with cacodylate

PERTUSSIS

434

MEDICAL ANNUAL

of sodium or some similar remedy. The infective element appears to
\’anish with the parox^^sms, the cases shortly afterwards losing their
infecti^dty, and no longer calling for specific treatment. Mather SilP
has used the original vaccine in thirty-six cases, and a mixed vaccine,
consisting of B. pertussis, Staphylococcus aureus, and M. catarrhalis, in
ten others. The average length of time taken to produce a cure in the
first series was four and a half weeks. In the second series, the average
duration of the attacks after vaccine treatment was begun was three
and a half weeks. He regards vaccine-therapy as the best treatment
for the disease. He also used it as a prophylactic measure in three
children who, though exposed to infection, did not contract the malady.
Lagane*^ believes that antipertussis vaccine will prove of greatest value
as a prophylactic agent.

References. — Med. Jour. 1912, ii, 1748 ; ^Ihid. 1913, ii, 122 ;
^N.y. Med. Jour. 1913, i, 176 ; ^Ibid. S23 ; ^Amer. Med. 1913, 440 ; ^Presse
MM . 1913 606.

PINEAL GLAND. Herbert French, M.D., F.R.C.P.

Simultaneously with the experimental, surgical, and clinical investiga-
tions that are being made upon the functions of the pituitary body,
similar work is being carried out in connection with the pineal gland.
A full review is given by L. J. Kidd,^ whose general conclusions are that
the pineal gland, far from being merely a degenerating morphological
remnant, has important functions in all animals possessed of the organ ;
and that one of the chief of these functions is control of the development
of the genital organs in the male, and possibly also in the female. A
prominent feature of cases in which pineal tumour has developed in
childhood is precocious hypertrophy of the penis and testicles, with
development of pubic hair in infancy ; whilst at the same time the
metabolism of the body generally and of the nervous system is abnormal ,
resulting in overgrowth of the subcutaneous fat and under-development
of the mental powers. This recalls the similar changes that may
result from disorders of the pituitary body or of the suprarenals ;
possibly there is an interrelationship between the three.

Berkeley, in the same paper, records the apparent good results, and
the enthusiasm aroused among the teachers, by the use of pineal gland
in the treatment of certain backv-’-ard children in a New York School.
In making the preparation, twelve bullocks' pineals, perfectly fresh,
were rubbed up with a suitable amount of milk sugar till extinguished ;
the mass thus obtained, after thorough drying, was distributed into
one hundred capsules ; and the dose employed was from two to three
of these capsules per day. The protocols of the cases are given, and
from them one is not as much impressed by the evidence of therapeutic
benefit as the actual observers of the patients appear to have been ;
but there are indications that the treatment merits extended trial and
further investigation.

The following table of comparison between pituitary and pineal-
gland defects has been dra^vn up by Dana and Berkeley 2 : —

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435

PITUITARY BQDY

Pathological and Physiological Effects Attributed to the
Activities or Disorders of the

Pituitary Body

Adiposity
Sexual changes

Genital atrophy and infantilism
Acromegaly and gigantism
Polyuria

Control of carbohydrate metabol-
ism

Lowered temperature
Co-ordinate action with other glands

Physiological action of extracts of the
gland : —

Pressor and depressor effects on
blood-vessels
Galactagogic effect
Stimulation of muscles of pupil,
uterus, and intestines
Modifications of metabolism and
bodily growth

Modification of carbohydrate meta-
bolism

Pineal Body

Adiposity (later sometimes a marked
atrophy of fatty tissues)

Early development of sexual organs
and functions

Earh' bodily and mental maturity
(Macrogenitosomia of Pellizi)

Physiological action of extracts of the
gland : —

Contradictory reports as to pressor
and depressor effect on blood-
vessels

Stimulation of unstriped muscular
tissue of intestines, uterus, pupil

Vasodilatation of genitalia and
kidney

Transitory diuresis

Glycosuria

Stimulation of metabolism (Berke-
ley)

References. — ’^Med, Chron. 1912, Dec. 154 ; ^Med. Rec. 1913, i, 835.

PITUITARY BODY, DISEASES OP. {See also Brain, Surgery of;

Diabetes Insipidus.) Herbert French, M.D,, F,R.C,P,

Cushing^ suggests that disturbance of the pituitary gland secretion
is responsible for the s^oidrome of Frohlich described by the term
dystrophia adiposogenitalis,” and believes that this syndrome arises
when there is hyperplasia of the anterior lobe of the pituitary body
simultaneously with secretory stasis or insufficiency of the posterior
lobe. It may develop gradually from early infancy onwards, or it may
occur rapidly in later life when there has been no indication of the
overgrowth of the fatt^" tissues and of the genital organs in childhood.
Fig. 44 indicates the kind of clinical condition that results.

In some of Cushing’s cases there were definite signs of cerebral tumour ;
but he holds that it ought to be possible to recognize hyperpituitarism
and hypopituitarism in cases in which there is no actual tumour-
formation. The patient as a rule suffers from polyuria, polydipsia,
and polyphagia. He points out that the functions of the pituitary
gland may be interfered with considerably, not merely by tumours
in, or in the immediate neighbourhood of, the gland itself, but also
by lesions situated in the brain at a distance from the pituitary
body. He discusses^ cases of dyspituitarism under the following
headings : (i) Those in which not only the signs indicating distortion
of neighbouring structures, but also the symptoms betraying the
effects of altered glandular activity, are outspoken ; (2) Those in which
the neighbourhood^manifestations are pronounced, but the glandular

PITUITARY BODY 436 MEDICAL ANNUAL

S3^mptoms are absent or inconspicuous ; (3) Those in which neighbour-
hood manifestations are absent or inconspicuous, though glandular
symptoms are pronounced and unmistakable ; (4) Those in which

obvious distant cerebral lesions are accompanied by sj^mptomatic
indications of secondary pituitary involvement ; (5) Those with a
polyglandular syndrome in which the functional disturbances on the

44. — Case of dystrophia adiposogenitalis.

part of the hypophysis are merely one, and not a predominant, feature
of a general involvement of the ductless glands. Under each of the
first four groups there will naturally occur three subdivisions, namely
{a) The cases in which the clinical manifestations of past or of existing
hyperpiiuiiarism predominate (more particularly overgrowth resulting
in gigantism when the process antedates ossification^of the epiphyses —

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437

PLAGUE

typiis Launsis ; resulting in acromegaly when it is of later occurrence —
typus Marie) ; (6) Those in which the clinical manifestations of hypo-
pituitarism predominate (adiposity, with a persistence of both skeletal
and sexual infantilism when the process originates in childhood — typus
Frohlich ; adiposity with sexual infantilism of the reversive form when
it originates in the adult — a type he has explained on experimental
grounds) ; and [c) The mixed or transition cases exhibiting features of
both states.

Von Bonin^ also records full details of a case of dyspituitarism, and
summarizes the literature. He believes that the abnormal growth
changes in acromegaly are not confined to the skeleton, or indeed to
any part, but occur ever5rwhere, their degree depending upon the
intensity of the stimuli acting upon the difierent tissues. He holds
that acromegaly is in all probability due to an excessive acthdty,
whilst sexual infantilism, as also a general diminution of metabolism,
is due to a deficient activity of the anterior lobe of the pituitary body.
On the other hand, deficiency in either the anterior or posterior lobe
produces adiposit>^ He also points out that some of the tumours of
the pituitary body which appear at a first glance under the microscope
to be sarcomatous, are really cellular overgrowths of the gland, and
calls them round-celled adenomata.

References. — Kimer. Jour, Med. Sci. 1913, i, 313; ^Pituitary Body
and its Disorders, Lippincott, London, 1912 ; ® Quart. Jour. Med. 1913,

Jan, 125.

PLAGUE, Leo 7 iard Rogers, M.D., F.R.C.P,

R. P. Strong^ has recorded a full account of his experiments in
relation to pneumonic plague carried out at IManila after his return
from studying the great Manchurian epidemic, which throw important
light on that remarkable outbreak. After giving a graphic description
of the conditions of work at IMukden during the actual epidemic, he
records experiments on the method of transmission of the infection of
pneumonic plague. The exposure of plates of culture media within
short distances of the mouths of the patients showed that the plague
bacilli are not disseminated b}’ deep breathing alone, but if talking or
coughing occurs the organisms are expelled in small droplets of moisture
and can be easily growm, so that direct infection through the air is easy.
As many as one hundred colonies were sometimes obtained in almost
pure culture after a single cough. No definite bacteriological evidence
has been produced that healthy carriers ever transmitted the disease.
Every patient in whose sputum plague bacilli were found, died of the
disease. Experiments were also carried out by O. Teague and M. A.
Barber on the influence of atmospheric temperature and moisture
upon the spread of pneumonic plague. It will be remembered that
the Manchurian epidemic occurred during intense cold, down to as
low as 30° C. below zero, and vaiydng between — 9° and - 32° C. At
such temperatures the rate of evaporation of moisture would be
only from to of its rate at a temperature of 30® C. and
70 per cent of humidity, such as often occurs during the prevalence of

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438

MEDICAL ANNUAL

bubonic plague in India. A series of experiments showed that plague
bacilli died less rapidly than cholera vibrios, but more quickly than M.
pYodigiosiis, when exposed to drying in the air. At ordinary tempera-
tures the latter, when sprayed into the air in fine droplets of moisture,
died in a few minutes, but at a cold temperature and in a saturated
atmosphere they remained alive for a very much longer time. As the
infection took place in the Manchurian plague-pneumonia epidemic
during intense cold, and in terribly close and overcrowded rooms, in
which the air soon becomes nearly saturated with moisture, the spread
of the disease to constitute a formidable epidemic, such as has never
occurred in the totally different air conditions of the plains of India, is
readily explained. It is also of interest to note that the only appreci-
able plague pneumonia outbreak in India actually occurred in Cashmere
during very cold weather.

In the next section Strong and Teague record experiments on the
mode of infection of pneumonic plague by exposing animals in con-
fined atmosphere into which a fine spray containing plague bacilli
is passed for a short time. In the case of guinea-pigs, infection took
place through the throat and tonsils, pneumonia being only rarely
produced. On the other hand, in the case of monkeys, primary plague
pneumonia was always produced in this way, while it was very rare for
the throat glands or tonsils to be infected. Primary plague septicaemia
may occasionally arise, though rarely before visible lesions have taken
place either in the lungs or lymphatic glands. These experiments fully
explain the mode of direct infection in pneumonic plague and the
deadliness of the disease, as the organisms are present in far larger
numbers in the lungs than they are even in the spleen in other modes
of infection.

The pathological anatomy is next described, and illustrated by a
number of excellent coloured plates. A number of strains of plague-
pneumonia bacilli were carefully studied, but they were not found to
be more virulent than those from the common bubonic forms of the
disease, nor were they less virulent towards the end of the outbreak
than earlier. The susceptibility of several animals said to have been
infected during the epidemic was tested. Tai'bagans, a species of
marmot incriminated in the origin of the outbreak, were readily inocu-
lated with the disease, and could also be infected through the lungs on
being made to inhale plague bacilli. Donkeys could not be infected
by the latter method ; while dogs were only moderately susceptible.

Strong and Teague also investigated inoculation as a protection
against pneumonic plague ; but although a non-virulent living culture
was used, no appreciable success was obtained with the experimental
animals. M, A. Barber experimented with accurate doses of one
plague bacillus upwards, and showed that even a single organism may
suffice to infect, but that animals infected with very small numbers
survived nearly twdce as long as those receiving three-fourths of a
million or more. These observations support the view of the English
Plague Commission that sufficient bacilli may enter the abraded skin

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439

PLAGUE

from the faeces of infected fleas, whose intestines may contain very
large numbers of plague bacilli. Lastly, this ver^’- valuable report
concludes with experiments to determine if the masks ’worn over the
nose and mouth while attending pneumonic plague cases at Mukden
are efficient in keeping out bacteria sprayed into the air. A pad of
cotton-wool bandaged over the face did not prove to be completely
bacteria-proof, although it appears to have afforded veiy^ great protec-
tion in actual practice. Somewhat better, but not perfect, results
were obtained with Bronquet*s mask, made in the form of a complete
hood of light canvas or khaki cloth completely covering the head, in
the front of which is a window ofjmica or sheet ceLloidin. It is there-
fore clear that, even with these masks. Strong was exposed to very
great risks while carrying out his invaluable investigations among the
pneumonic plague cases in Manchuria who, before his arrival, had
received practically no attention through fear of infection.

The English Plague Commission have issued the seventh report of
their investigations, ^ which deals with a variety of points. The causes
of the remarkable immunity of Madras city to any extensive infection
have been enquired into. A sufficiency of rats and fleas was found,
while the rats were far more generally susceptible to the disease than
in many places which have suffered from plague. A small outbreak
did occur on the outskirts of the town, but was promptly and adequately
dealt with by the sanitary authorities, and apparently eradicated. The
passport system, introduced by Colonel King, lately Sanitary Commis-
sioner of Madras, must be given credit for at least limiting the importa-
tion of cases of the disease, while his good sanitary organization has
proved of great value in preventing a foothold being obtained
in the Presidency town of Madras, the only Indian town of its kind
to have escaped a severe epidemic. Further statistics regarding
human and rat plague in Bombay are recorded. Extensive inocula-
tions of wild rats caught in various parts of India, to test their degree
of immunity, have been carried out, which clearly show that they are
most immune where plague has been most severe and prolonged, and
least where epidemic plague has not occurred, as in jMadras city. This
immunity may be transmitted by the parents to their offspring who
have not been exposed to plague. Chronic and resolving plague is
again dealt with at length, and many neAv data are recorded, while the
condition has been produced experimentally, and its stages traced.
Further experimental plague epidemics in rats are recorded, which
confirm previous ones. Interesting observations on flea-breeding are
given, which show that the process is most active in wet weather with a
moderate temperature, and least active under dry and hot conditions,
the humidity being the most important factor at Poona. The seasonal
variations correspond to those of the natural prevalence of fleas on
rats. Adult fleas live longer in a cool and moist atmosphere than in a
hot dry one.

J. Guiteras® describes a small outbreak of three cases of plague at
Havana, in which vigorous steps were taken to destroy rats and disin-

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440

MEDICAL ANNUAL

feet the houses, with the result that during the following tw^o months
no further cases occurred. R. H. CreeR deals with the eradication of
plague in Porto Rico. The most important measures were making the
houses rat-proof, and trapping the rats. The infection w^as discovered
within four days of its importation ; and when the rats were reduced
to about half the original numbers, plague cases ceased to occur, the
duration of its prevalence having been eighty-four days. The infection
appears to have been carried to some other towns through freight. By
the inspection of packages which might harbour rats, a number were
caught. The average number of fleas on the rats was low^

W. Glen Liston^ contrasts the epidemiological features of bubonic and
pneumonic plague, and shows that the rats of towns which have repeat-
edly?^ suffered from plague develop a relative immunity to the disease.

Wu Lien Teh (G. L. Tuck) ® has investigated the relationship of the
tarbagan (Mongolian marmot) to plague, and concludes that although
this animal occasionally suffers from the disease, the epizootic is never
extensive, and does not play nearly so important a part in the spread
of plague as does the rat. In fact, the direct relationship of the marmot
to human plague may be considered negligible.

Treatment. — Aumann’ reports one case of plague treated with
Salvarsan intravenously, the patient dying after eleven days without
any evident result from the treatment. F. P. Connor® records three
cases of plague in which 7 min. of Tincture of Iodine in i dr. of distilled
water was repeatedly injected intravenously, wdth recovery in all three,
although one was a very severe case.

Fiu'ther trials of Anti-plague Serums have been made by the English
Plague Commission* ■whose report is discussed above, under carefully
controlled experimental conditions, and the conclusion is reached that
they are at present of very little use, and do not constitute a practical
method of reducing the mortality from plague in India. The latter
part of the report is occupied with papers by S. Rowland on his further
studies at the Lister Institute of the production of immunity by means
of the nucleo-proteid he has separated from plague bacilli, which are of
a highly technical nature. He has been unable to confirm Besredka's
statement that sensitized organisms yield an atoxic vaccine. R. St.
J. Brooks contributes a section on the opsonic index in plague vac-
cination, and finds that only the nucleo-proteid aflects it. Lastly,
MacConkey deals with the preparation of antitoxic plague serum,
but finds that so far, its antitoxic value has not been high.

A. P. Goff^ describes an outbreak of plague at Manila after six
years’ freedom. The disease is thought to have been introduced from
China, Immediate steps were taken to capture and destroy rats,
very few of which were found to be infected. The best poison was
arsenic mixed -with rice, so that a few grains of the latter formed a fatal
dose. Gland puncture on admission, with cultures and guinea-pig
inoculations, were used for diagnostic purposes ; by such means alone
can climatic buboes ” be distinguished from plague during the first
two or three days. Large doses of Serum prepared in the Government

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441

PLEURAL EFFUSION

laboratory were injected intramuscularly ; 20 per cent of the admis-
sions and 12 J per cent of the total cases recovered.

R. Row^” records favourable results in the treatment of non-septicaemic
plague in Bombay with a glycerinated pest Yaccine,

References. — Jour. Med. Sci. 1912, 521 ; ^Jour. of Hyg. 1913,
Plague Suppl. ; ^Jour. Amer. Med. Assoc. 1912, ii, 1780 ; ^Ibid. 1913, i, 1527 ;
^Jour. Trop. Med. 1913, 237 ; ^Lancet, 1913, ii, 529 ; '^Deut. med. Woch. 1912,
2166; ^Jour. Lond. Sch. Trop. Med. vol. ii. Pt. 2, 14S ; ^Jour. Amer. Med.
Assoc. 1913, i, 2042 ; '^^Jour. Trop. Med. 1913, 293.

PLEURAL EFFUSION. {See also Empyema ; Lung, Surgery of.)

J. J. Perkins, M.B., F.R.C.P.

Treatment. — ^V. Gilbert in 1891 first treated tuberculous pleurisy
with Serofibrinous Effusion by the subcutaneous injection of a small
amount of the fluid withdrawn by the aspirator. He found that within
a few days after, the pleural exudate disappeared. This method,
Fishbergi says, is now gaining recognition, and Eisner’s experiments
prove that it has a scientific basis. During the last four years he has
tried it in twelve cases, and though it is not uniformly successful, he be-
lieves that it has sufficient merit to warrant its more general adoption.
A syringeful of the fluid is withdrawn, and the cannula pulled out until
it has left the pleural cavity ; it is then turned round into the sub-
cutaneous tissue at the site of puncture, and the aspirated fluid slowly
expelled. Of course the fluid may be injected into the cellular tissue
in any region. Fishberg has found the injection of 2 to 5 c.c. just as
satisfactory as larger quantities. The events wliich follow in a
successful case are increased diure.sis, and the gradual diminution of
the effusion, until within a week or ten days the fluid has entirely
disappeared. The advantages of the method are entirely confined to
its effects upon the pleural effusion, no influence having been observed
on the after-development of the tuberculosis. The method may have
to be repeated sevei*al times before the fluid is completely absorbed.

An illustrative case may be quoted — a child, aged 5, suffered from a
pleural effusion filling about three-fourths of the right chest and producing
profound dyspnoea. During the three weeks effusion was present, exploratory
puncture was performed twice, and once 7 oz. of fluid were removed by the
aspirator, but the fluid reaccumulated within three days. Soon, after the
injection of 3 c.c. of the fluid into the subcutaneous tissue of the chest, the
effusion began to show signs of absorption, and disappeared within a week.
Of course not all the cases were so completely successful, while it must be
owned that in some the method was a complete failure.

Vaiious theories have been advanced byway of explanation, but none
that is universally accepted. One fact which is interesting is that after
autoserotherapy leucocytosis occurs, the cell-count in one instance
rising from 7,800 to 15,000. It has been suggested that the accumu-
lation of autolytic products in the exudate is r-esponsible for its absorp-
tion. Zimmermann found that an injection of a solution of peptones
brings about leucocytosis, and also increased diuresis, just as after
autoserotherapy.

Reference. — '^Jour. Amer.' Med. Assoc, 1913, i, 962.

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PNEUMONIA. (See also Pneumonia, Epidemic.)

/. /. Perkins, M.B., F.R.CP.

Treatment. — Fleming^ controverts the usual view that the firm,
opaque, fibrinous clots found in the right heart in croupous pneumonia
are due to post-mortem clotting ; in his eyes these clots are of ante-
mortem formation, and from this he deduces important clinical lessons.
The frequency of such clotting is seen from his post-mortem statistics ;
in 61 cases of lobar pneumonia, 39 showed ante-mortem clotting in the
right auricle, right ventricle, and pulmonary arteries. Of the 39, in
16 the clot was adherent and extensive, while in the remaining 23 it was
mostly colourless but nonradheient. By way of contrast he examined
162 consecutive cases post mortem, eliminating those of lobar pneu-
monia, and found ante-mortem or colourless clotting in only 20. Hence
he argues that Stimulation of the Heart should be the routine treatment
for all cases of croupous pneumonia, and he would give early and
continuously a direct cardiac tonic, such as digitalis or strophanthus.
Diffusible stimulants should be given at once if the heart shows any
signs of difficulty. The most obvious signs of such thrombosis are
engorgement of the jugular vein, and weakening and later disappearance
of the pulmonary second sound. He keeps a careful watch on the
veins of the neck, and the slightest engorgement indicates the need of
increased stimulation. Equally important is the second sound in the
pulmonary area. In almost every one of his cases in which post mortem
there was extensive ante-mortem clotting, the right heart was markedly
dilated. The failure of the second sound in croupous pneumonia,
however, means more than cardiac failure ; thrombosis has begun, and
the thrombus is mechanically interfering with the closure of the
pulmonary valve. In addition to those measures mentioned above,
he believes in the use of Oxygen to counteract the excess of CO which
according to Wiener aids clotting, and in Change of Position. He
would, however, allow Bleeding only in particularly robust patients,
as it may only promote thrombosis. Citric acid he considers futile.

Vetlesen® reports 9 cases of croupous pneumonia treated by Ethyl-
hydrocuprein, the drug introduced in the early part of 1912 by
Morgenroth, from the use of which so much has been hoped. The
cases reported w^ere in hospital patients taken in ordinary succession
as admitted, not especially benign, and placed under treatment at an
early stage. The drug was given in three separate doses daily
of 0*5 gram, in obedience to Morgenroth’s dictum that transient disturb-
ances of vision, such as may appear after its use, necessitate caution,
and that therefore the total amount administered should not exceed
1*5 gram per diem. Of the 9 cases, defervescence occurred in 3 in less
than forty-eight hours after the onset of the disease ; in 2 cases after
two and a half days ; in 2 more in three days and a half ; in i after
four days ; and in i after eight days. In tw^o other cases in which it
was given, death occurred, but one of these was found post mortem
to be a case of tuberculosis, though no tubercle bacilli were found in the
sputum during life ; the other a case of gangrene possibly due to

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443

PNEUMONIA, EPIDEMIC

malignant endocarditis. The 9 cases of croupous pneumonia all
recovered, and Vetlesen’s verdict on the drug is generally favourable,
as he believes it tends to shorten the course of the disease, though he
insists that it must be given at the earliest possible moment.

This favourable verdict is hardly borne out by Sir Almroth Wright’s**
investigations. His experiments at first sight seem to be of good
promise ; while ordinary antiseptics expend their energy wastefully
upon the blood fluids, we have in the new drug a chemical agent which
exerts its effect practically undiminished in serum. For example, one
part of lysol in 62,500 parts of water kills the pneumococcus, but one
part in 500 parts of sera is required ; whereas for ethylhydrocuprein
I part in 400,000 parts of serum kills the pneumococcus, and i in
800,000 inhibits the growth. The antiseptic values of the serum
dilutions of the drug do not differ appreciably from the values obtained
from watery solutions, showing that the drug exerts its bactericidal
effect specifically upon the pneumococcus. Morgenroth’s own experi-
ments on mice inoculated with cultures of pneumococcus which killed
without exception every untreated mouse, showed that if it was
administered beforehand it prevented the development of the infection
in some 90 per cent of the animals, and cured about 50 per cent if given
after inoculation. Unfortunately, it could not be found that the
course of pneumonia in man was favourably influenced by its exhibition,
at any rate to any great extent, and in this Wright is at one with many
observers. He lays stress on the tendency of the drug to cause
amaurosis, and places this new discovery in the class of drugs which
are either useless or doubtfully efficacious.

Solis-Cohen* still upholds the great benefits which result from
massive doses of Quinine in pneumonia. He now uses the double
hydrochloride of urea and quinine, a 50 per cent solution being injected
intramuscularly. A fairly strong adult receives as an initial dose
15 to 25 gr., and the injection is repeated, but with a dose not exceeding
15 gr. every third hour until the temperature falls and remains below
102*2° F. One -half grain of Cocaine or of Caffeine, or i c.c. of i-iooo
posterior Pituitary principle, is injected hypodermically at the same
time, and repeated every third hour until the systolic blood- pressure
measured in millimetres of nieicury rises and remains above the pulse-
frequency in beats per minute (Gibson’s law). He does not think it
wise to continue the three-hourly injections after the first twenty -four
hours ; but in cases where the desired effect has not been reached, they
are continued at intervals of six hours.

References. — ^Edin. Med. Jour. 1913, ii, 213 ; ^Berl. hlin. Woch, 1913,
1473 ; ^Lancet, 1912, ii, 1633 ; ^Jour. Amer, Med. Assoc. 1913, ii, 107.

PNEUMONIA, EPIDEMIC. E. W. Goodall, M.D.

In the spring of 1 91 1 an outbreak of an acute febrile disease occurred
in a boys’ industrial school at Tranent, near Edinburgh. As during
the years 1900 to 1911 a series of similar outbreaks had taken place in
this school, an investigation, ordered by the Home Office, was made
by Charles M’Neil and J. P, M'Gowan, who have published a report.

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MEDICAL ANNUAL

The number of boys in the school is usually about 170. Their ages
range from five to sixteen years, but most of them are ten or over.
The total number of cases during all the outbreaks was 246. The
reporters found that they could divide these into three classes, but
that there were certain symptoms common to all.

The onset was exceptionally sudden and attended with great prostra-
tion, headache, vomiting, and high fever. Coma and delirium in varying
degree were present in a large proportion. Even in the mildest there
was a kind of stupor. Mental irritability was observed in several.
Sharp pains in the back, muscular cramps, and twitchings were fairly
common. There was cyanosis, with a rapid, weak, and irregular pulse.
The respiration-rate was but slightly affected. In some of the fatal
cases there was Cheyne-Stokes breathing. But the grunting, short,
laboured breathing, characteristic of typical lobar pneumonia, was
notably absent.’' Cough and expectoration are as often absent as
present in the pneumonic cases ; the sputum is rusty, but never sticky ;
in several of the fatal cases there was a slight cough, with scanty,
sanio-purulent expectoration. Herpes was occasionally present. The
blood showed a polymorphonuclear leucocytosis more or less marked.

The three groups of cases vrere as follows : Group I (acute fatal
illness, 20 cases). Death took place in a few hours from the onset.
In t^vo cases, indeed, the boys were found dead in bed in the morning,
after -having gone to bed apparently in good health on the previous
evening. Group II (pneumonia, 51 cases). The symptoms and
duration were somewhat variable. Group III (febricula, 175 cases).
The symptoms closely resembled the pneumonic cases, but evidence of
lung consolidation was wanting.

The outbreaks occurred mostly in the colder seasons of the year,
especially the spring. In respect of contagion, only the evidence
afforded by the last epidemic (1911) was available, and this was
negative.

Of fourteen cases examined post mortem, in only one were the lungs
normal. In the rest there was an acute general congestion or an
irregular patchy pneumonia ; in none was there a lobar pneumonia.
In a few specially examined cases the mesenteric glands and glands of
the intestines were enlarged. The spleen was also enlarged ; in five
cases the thymus, and in three the th3^roid, was larger than normal.
In eight cases in which a bacteriological examination was made, pneu-
mococci were obtained from the lungs, and in some of the cases from
the blood and other tissues. The boys in this school were found, as
regards nutrition and development, to be considerably below the
averages for similar ages of the general population ; 13*5 per cent of
them were subjects of a chronic granular or follicular conjunctivitis,
and 37 per cent suffered from some form of conjunctivitis. Enlarged
tonsils and adenoids were frequent. Von Pirquet’s tuberculin reaction
was positive in 59 per cent of the boys, as compared with 14 per cent
in another school of a similar kind which was examined as a control ;
and the reactions were unusuallv intense.

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445 PNEUMOTHORAX, ARTIFICIAL

In respect of the cause of the outbreak, the reporters say : In the
various conditions of environment the boys at Tranent are, in our
opinion, unduly exposed to cold, both from their too scanty clothing
in the cold seasons, and also in the lack of heating arrangements in the
dormitories and passages of the institution. There is also an inadequate
allowance of air space in the dormitories, which may, to some extent,
be mitigated by the free ventilation which is maintained.” They are
inclined to attribute the rapidly fatal event in some of the cases to a
concomitant condition of status lymphaticus ; and they suggest that
this may be the explanation of sudden and early death in the acute
infectious diseases.

Reference. — '^Edin. Med. Jour. 1913, i, 201.

PNEUMOTHORAX, ARTIFICIAL. (See also Lung, Surgery of.)

J. /. Perkins, M.B., F.R.C.P.

The method of treatment, described in previous volumes of the
Annual, of introducing gas into the pleural cavity in cases of pulmonary
tuberculosis, has thoroughly established itself. Reports accumulate
on all hands of the advantages which acciue ; with increasing experience
the dangers of the process have been eliminated, and it has now passed
beyond the experimental stage. To show the universal interest excited,
it is enough to say that an International Pneumothorax Association
has been formed. The idea is to bring about collapse of the lung, and
produce in the case of pulmonary tuberculosis the absolute rest sought
in treatment of tuberculous lesions in other parts of the body, which is
so essential to cicatrization. By the collapse, stasis in the lymph-
channels is secured, the spread of the disease is checked, and toxic
absorption or auto-inoculation prevented. The final result is a profound
fibrosis, and how well the objects sought are attained is shown by
the fact that in the post-mortems that have been done in after years
on successful cases not a single fresh tubercle is to be found in the side
which has been compressed (Rist).

Accidents. — In the past most of these resulted from the ignox'ance
of the operator as to the exact position of the point of the trocar through
which the gas is introduced. In some instances the end has lain not
in the pleural cavity but in some vessel ; the gas being then turned on,
gas embolism of the cerebral circulation occurs with serious, and in
several instances fatal, results. The use of a manometer attached to
the trocar has removed this danger, and the operation only requires
ordinary care to be perfectly safe. When the needle has really entered
the pleural cavity, the negative pressure produced by the elasticity
of the lung shows itself at once in the column of water in the manometer,
and marked oscillations of the column corresponding to the changes in
pressure brought about by inspiration and expiration are seen. If,
on the other hand, the point of the needle lies in a vessel or has pene-
trated the lung, these evidences of negative pressure and respiratory
movement are absent.

Technique. — A trocar and cannula are joined up to a manometer

PNEUMOTHORAX, ARTIFICIAL 44O

MEDICAL ANNUAL

and a reservoir of nitrogen, this gas being chosen because of its slow
absorption by the pleura. A three-way stopcock enables the operator
to place his instrument in communication with the manometer or with
the reservoir of nitrogen. The manometer is always in connection
with the trocar and cannula until the operator is thoroughly satisfied
that he has entered the pleural cavity. Then, and then only, he turns
on the nitrogen, and after the gas has begun to run makes use of the
manometric reading to show the pressure that he has brought about
within the pleural cavity ; as the gas flows in, the reading of the
manometer slowly changes from negative to positive.

Two methods of reaching the pleural cavity have been devised. In
one, a comparatively free incision is made through the skin and sub-
cutaneous tissues, and the muscles are separated by some blunt
instrument until the parietal pleura is exposed. The advantages of
this method are that the operator can tell exactly when his trocar and
cannula are entering the pleural cavity, and that he can see beforehand,
by the movements through the thin parietal pleura, whether the spot
that he has chosen is free from the pleural adhesions which, by defeating
his efforts to collapse the lung, are the heie noir of the operation. On
the other hand, beside difficulties which it is not necessary to mention,
surgical emphysema is rather apt to ensue, and whatever the importance
of this inconvenience, the operator cannot repeat his incision ad libitum,
so that to a considerable extent his hands aie tied if his original site of
operation is unsuccessful. The second method of reaching the pleura
by merely pushing the trocar and cannula through the chest wall, as
in ordinary aspiration of a pleural effusion, is free from these disabilities,
and is apparently coming into almost general use. Many operators
make a small incision through the skin, and then push a cannula with
a blunt trocar through the muscles, until a sudden yielding and loss of
resistance show that they have entered the pleural cavity. In this
way all danger of puncturing a vein is removed. Whichever method
is employed, however, it must be insisted that the only true criterion
of the entrance of the instrument into the pleural cavity is to be found
in movements of the manometer.

The choice of site for operation will be determined by the absence
of pleural adhesions, and every effort must be made to decide this
point, though after the closest investigation their presence or absence
often remains problematical. It is hardly necessary to insist upon the
importance of this point, as it is self-evident that an operation which
seeks to separate the two pleural surfaces widely from one another by
the introduction of gas, and so to collapse the lung, must be impossible
if those surfaces are firmly bound together by strong adhesions. A
spot therefore, usually in the lower part of the thorax, where the
percussion note is resonant and the breath sounds are strong and free
from evidence of disease, is chosen ; to make certain as far as possible
the best procedure employs the A'-rays in addition, and endeavours
to search out not only the condition of the lung at the selected spot, but
also the degree of movement of the lower border of the lung, which is

NEW TREATMENT

447 PNEUMOTHORAX, ARTIFICIAL

of course more free to move in the absence of extensive adhesions.
Even with all these precautions, however, it is evidently impossible
to make certain of the presence or absence of adhesions until trial has
been made. The patient is placed upon the opposite side, with a pillow
beneath him to effect the greater separation of the ribs ; a hypodermic
injection of morphia gr. \ to (Maxon King) may be given . and i or 2
per cent solution of novocain is injected, at first beneath the skin,
then into the deeper tissues, and finally by many into the pleural sac
itself, with the object of reducing the possibility of the symptoms
known as “ pleural reflex,” i.e., syncope, which may be fatal, and which
occasionally has been known to follow the aspiration of the chest for
fluid. In the earlier days of attempted artificial pneumothorax, a
number of cases with symptoms of a dangerous syncopal nature were
observed on the introduction of the trocar and cannula. The origin
of these symptoms has been much debated, some ascribing them to
pleural reflex, others to gas embolism in minute veins ; but Forlanini
has shown experimentally that symptoms of this nature may be avoided
if the pleura itself is anaesthetized before the introduction of the .trocar
and cannula. The skin must be previously sterilized by the iodine
method ; ethyl chloride may be employed to anaesthetize the skin
itself, though this seems hardly necessary. The trocar and cannula
are then introduced, the sharp stilette is changed for a blunt one, and
' when the manometer shows that the instrument lies in the pleura and
that adhesions are absent, the gas is turned on.

The presence of adhesions, as stated, is shown by the absence of
the usual negative pressure and wide respiratory oscillations, or by the
fact that after the introduction of a small quantity of gas the pressure
becomes positive, and highly so if the introduction of gas is persisted
in. Many excellent cases are reported of a gradual stretching and
breaking down of adhesions by the repeated introduction of gas until
almost complete collapse of the lung is attained, but such a procedure
is, of course, not devoid of danger, and is rather for the expert. A
golden rule for the novice, which will relieve him of danger and anxiety
is only to introduce gas when the manometer shows him that he has
entered the pleural cavity at a spot where it is free from adhesions.
If he is unsuccessful in his first attempt, let him try some other spot,
wheie he may be more successful.

Some difference of practice exists as to the amount of gas which
should be introduced at the first attempt after the open pleural cavity
has been struck. Some advocate small quantities, others larger, from
Ihe convenience thus gained in the subsequent refilling of the pleural
cavity, which has to be frequently performed. Five or six hundred c.c.
of gas seems to be a reasonable figure ; and as regards pressure, Rist
(whose paper is largely followed in this article) and many others are
content with a slight positive pressure as shown on the manometer
— 2 to 4 cm. of water, which is sufficient to keep the lung perfectly
compressed. All are agreed as to the necessity of allowing the gas
to run in slowly ; a rapid inrush or a high positive pressure has been

PNEUWOTHORAX, ARTIFICIAL 448

MEDICAL ANNUAL

known not only seriously to inconvenience the patient, but to cause
the ejection of the contents of a cavity in the lung, followed by aspiration
into, and infection of, the opposite lung.

The nitrogen introduced is rapidly absorbed from the pleura, so much
so that at first fresh gas has to be introduced at the end of a day or
two. Subsequently the absorptive power of the pleura lessens, and
refills are only needed at longer intervals. These refills are done by
means of a hollow needle — ^the pleural surfaces now being separated, —
pushed through the chest wall, but under the guidance of the indispens-
able manometer. Gradually, as the lung is more or less completely
compressed, the amount of gas can be increased, and it must be
remembered that the object of the whole procedure is to compress and
immobilize the lung as completely as possible and keep up a small
positive pressure in the pleura. All are agreed that the constant use
of the ;tr-rays is the only means of determining the position of the gas
and the condition of the lung, i.e., in what condition of compression it
is. If the interval between the refills is allowed to become too long,
too much of the gas is absorbed, and the lung begins to expand and
regains a certain degree of movement, which is fatal to the success
of the treatment.

Kesults. — After some time the interval between the refills is quite
a long one, e.g., a month, and though the patients are of course kept at
rest at first, they can walk later on, and, indeed, perform light work.
Nothing is more striking than the absence of the distress one would
have expected to follow the presence of such large quantities of gas
in the pleural cavity. A most marked amelioration of symptoms
follows successful artificial pneumothorax, the temperature falls, the
sputum lessens, the night sweats disappear, the appetite and general
health striking^ improve, and a bedridden hopeless invalid has often
been restored to active life. Though it may sound incredible, it is
a fact that severe laryngeal tuberculosis not only is no bar to the
procedure, but is strikingly benefited from the cessation of cough and
the improvement in the general health (Vere Pearson).

In about 50 per cent of the cases, artificial pneumothorax is followed
by the advent of a pleural efiusion, which may or may not be accom-
panied by fever. It rarely requires tapping, and usually serves the
purpose of diminishing the necessity for further injection of gas. If
the pressure becomes too great, some of the fluid may be removed. Its
formation is shown by the presence of a succussion splash and by the
X rays, dullness on percussion naturally not being obtainable until the
effusion has become quite considerable. The effusion remains serous
almost without exception. The nature of this complication has
been much discussed, and various views have been advanced, but
Hist seems to have shown by inoculation experiments that it is
tuberculous.

The effects of the prolonged compression on a tuberculous lung have
been seen in cases which have come to post-mortem in after years.
They are quite extraordinary, and may be summed up as extreme and

NEW TREATMENT 449 PNEUMOTHORAX, ARTIFICIAL

extensive connective -tissue proliferation both in the lung and the
subpleural layer. Even a cavity may be obliterated and converted
into a firm scar. Of course, one must not expect from results like
these a complete re-expansion of the lung, but it becomes a very
good working lung, and, the chest wall falling in, the pneumothorax
can after a time be abolished. This is done by the simple process
of allowing the gas to be absorbed wdthout further introduction.
When to allow this is a matter for nice judgment, but Forlanini
expresses the opinion (Rist) that one should in no case wait for less
than one to tvm years.

Not many statistics have, of course, yet been gathered as to the
remote results of the treatment as regards duration of the recovery.
Spengler, how^ever, has reported a series of 15 cases in which the
pneumothorax had been ended for at least nine months, all of
them originally severe cases with fever, abundant bacilH in the
sputum, and, in eight, cavities. At the time of publication they
had all been without fever, without expectoration, and fully able
to work for more than a year (Rist). This is not to mention his
cases in which the pneumothorax still existed, however striking
their recovery.

Selection of Cases. — Hitherto the cases selected have been those
which have not responded to other modes of treatment. As these
have done so well, it is only natural to suppose that early cases would
do even better with this mode of treatment ; but as the early case as
a rule responds well to other methods, it is probably wise to follow
Maxon King and reserve artificial pneumothorax for comparatively
unfavourable cases. Forlanini himself (Maxon King) considers the
following as indications for treatment by induced pneumothorax;
(i) Uncomplicated unilateral phthisis with slow or subacute course,
without regard to the degree of the lesion, (2) Bilateral phthisis not
running an acute course and with lesions on both sides, but not far
advanced. To these may be added acute progressive tuberculosis of
one lung. The condition of the other lung, except in very severe or
desperate cases, is the criterion for interference. This for obvious
reasons must not show advanced disease ; but it is interesting to note
that a pneumothorax promotes the healing of an apical lesion on the
untouched opposite side, so that early disease on that side is no contra-
indication. Quite a number of advanced and extensive cases, it is true,
have received extraordinary and unhoped-for benefit, but of course
such cases stand on their own merits and are outside the ordinary rules.
Acute miliary tuberculosis must be excluded, and so must abscess of
the lung ; laryngeal tuberculosis is no bar, but intestinal ulceration is
excluded by all.

References. — Rist, Quart, Jour, Med. 1913. Jan. 259 ; Maxon King and
Mills, Amer, Jour, Med. Sci. 1913, ii, 330 ; Claude Lillingston, Lancet, 1913,
ii, 796 ; Ibid. 1912, ii, 1642 ; Parry Morgan, Ibid, 1913, ii, 18 ; Hamman and
Sloan, Johns Hop. Hosp, Bull. 1913, 53 ; Balboni. JBost. Med. and Surg.
Jour. 1912, ii, 755 ; Mary E. Lapham, Amer. Jour. Med. Sci. 1912, i, 503 ;
Dunham and Rockhill, Jour. Amer. Med. Assoc, ii, 826, 1913.

POLSOiViyELiTfS

450

MEDICAL ANNUAL

POLIOMYELITIS, EPIDEMIC. Pitrves Stewart, M.D., F.R.C.P,

Etiology. — Repeated observations in recent years on the subject
Oi poIioni}'elitis Jiave placed its infective origin beyond doubt, and the
brilliant investigations of numerous workers, especially of Flexner and
his pupils (see Medical Annual, 1912 and 1913) have succeeded in
ideiitif3nng the virus, and in reproducing the disease experimentally
in monkeys. McIntosh and TurnbulR have confirmed these observa-
tions by inoculation in monkeys in London ; but the English virus,
unlike the American or Continental strain, has not yet produced a fatal
disease in monkeys.

The mode of transmission of poliomyelitis is an important problem,
since in this, prevention is not only better than the most perfect means
of cure, but specially important, since at present we possess no true
curative or specific treatment for the established disease ; and because,
for the most part, by the time the disease is recognized in the human
subject it has already caused irreparable damage.

It is now well known that the virus of poliomyelitis occurs not only
in the spinal cord and brain, but also in the mesenteric lymph-glands
and in the mucous membranes of the nose, pharynx, and gastro-
intestinal canal, and in their mucous secretions. The distribution of
the virus in experimentally infected monkeys is the same as in spon-
taneously infected human beings. The virus, until recently, was not
known to be capable of cultivation apart from the infected monkey or
patient, and the only certain means of identifying it has been by its
transmission to monkeys. Recently, however, Flexner and Noguchi®
made fresh efforts at cultivation, and succeeded in growing colonies of
globoid bodies under anaerobic conditions in culture media, consist-
ing either of sterile ascitic fluid, or of brain-extract to which fragments
of sterile rabbit-kidney and a layer of paraffin oil had been added.
From each of these a second medium was made by adding nutrient
agar-agar in the proportion of i to 2. The first media permit of a
slow growth not visible to the naked eye, whilst the second (which are
unsuitable for obtaining the initial growth) yield visible minute colonies
clouding the tubes. The cultivated globoid bodies occur in various
arrangements — single, double, short chains and masses — and stain a pale
reddish-violet in Giemsa’s solution. Similarly stained bodies have
also been demonstrated by Noguchi in films prepared directly from the
nervous tissues of infected animals. Monkeys have been inoculated
with these cultures through several generations, and all the typical
phenomena of poliomyelitis have been reproduced.

The virus in man must enter the body by some external channel,
and it is highly probable that it does so through the uninjured nasal
mucous membrane, and' that this is the site both of its ingress and
egress. Clinical evidence points strongly to the fact that human
virus-carriers exist, and that these carriers, themselves healthy, may
transfer the disease from one person to another. Corroboration of
this view has been furnished by the Swedish investigators Klung,
Petterson, and Wernstedt,® who found the virus in the nasopharyngeal

NEW TREATMENT

451

POLIOMYELITIS

washings of patients, attendants, and friends ; by Osgood and Lucas, ^
of Boston, who found it in a case two and a quarter years after the
original infection ; and by Flexner, Clark, and Fraser,® who found it
in the parents of a child suffering from an acute attack of the disease.
Facts like these suggest strongly that the disease is caused by contagion,
despite the objections that it prevails more in rural than in urban
conditions ; that when it invades a city it is not specially frequent in
the poorer or congested areas ; and that cases of infantile paralysis
admitted to hospitals have not yet been known to infect others in the
same institution. The seasonal prevalence of the disease, which
attains its maximum during the summer months, is capable of various
explanations. Thus, it may be dust-borne ; and Neustaedter and
Thro® claim to have induced the disease in monkeys by inoculating
them with the dust found in sick rooms. But poliomyelitis, as Rosen au’
points out, does not show the common characteristics of a dust-borne
disease, so that this h5q)o thesis has been given scant practical attention.
Another possibility is, that it is insect-borne, the house-fly being a
possible contaminator, since, as shown by Howard and Clark, the virus
survives on the surface of the body of these insects and within their
gastro-intestinal tract.

In view of these various possibilities, the duty of the physician and
of the medical officer of health is to face and combat all of them, and
not to neglect any reasonable route of infection. Fortunately, the
spread of epidemics is limited by the fact that in many individuals of
all ages there is a natural insusceptibility to the disease.

The symptoms of the disease in the human subject are too familiar
to require detailed description. Suffice it to remind the practitioner
of its febrile onset with flaccid paralysis of limbs and trunk, often wide-
spread and asymmetrical, and associated with pains in the limbs, but
without anaesthesia or sphincter trouble. The paralysis recovers more
or less completely after a few days, leaving a residue of permanent
paralysis and atrophy in certain muscle-groups. The cerebrospinal
liuid in the early days of the disease shows an abundant pleocytosis of
the mononuclear type.

Colliver,® of Los Angeles, during a recent epidemic of poliomyelitis,
in which he observed sixteen cases, described a symptom which he
regards as pathognomonic of the pre-paralytic stage of the disease. It
consists of a peculiar tremulous twitching of certain groups of muscles
of the limbs, face, and jaw, sometimes localized, sometimes all over the
body. These tremors last only a second, but as the case progresses
they may last several seconds, or even a minute, recurring at frequent
intervals. Sometimes the twitch is accompanied by a peculiar hydro-
cephalic cry. The twitching resembles in some respects that of strych-
nine poisoning, since it is elicited or aggravated by slight stimuli, tactile
or auditory.

References. — ^Lanaet^ 1913* i» ^12 ; ^Jour. Amer. Med. Assoc. 1913, i,
362 ; ^Trans. XVih Internat. Congy. on Hyg. and Demogy. Washington, 1912 ;
^Jour. Amer. Med. Assoc. 1913, i, 1611 ; ^Ibid. 201; ^Ibid, 1615; ’^Ihid.)
mid. S13.

POLYCYTH>€W!IA

452

MEDICAL ANNUAL

POLYCYTHEMIA. Herberi French, M.D., F,R,C.P.

Eryihrcemia (Splenomegalic Polycythcamia ). — Details of six fresh cases
of erytiirsemia from the London Hospital are published by Parkinson, ^
and amongst the points which he brings out is the fact that the
spleen in these cases may ultimately become no longer palpable, though
at a previous stage it may have been large. The symptoms usually
appear in adults between the ages of thirty and sixty, and rather more
frequently in men than in women. Shortness of breath, blueness,
giddiness, and general weakness are among the earliest and most
constant complaints. In some patients the first symptoms are refer-
able. to the spleen, and consist of abdominal pains, usually on the left
side. Others complain of the presence of an abdominal tumour. The
change in facial appearance may not have been noticed by the patient.
Wasting and general weakness are frequent, but only severe when the
other symptoms are also troublesome. The subjects of erythraemia
are very liable to haemorrhages. Epistaxis, bleeding from the gums,
and haematemesis have often been remarked. Purpura occurred in
two of the cases here described. Headache occurs at some time during
the course of most cases. It often becomes continuous, and produces
a feeling of pressure or fullness whenever there is an exacerbation of
the general symptoms. Typical attacks of migraine are sometimes
a feature. The giddiness of erythraemia comes on in brief attacks ;
tinnitus is rare. Paraesthesiae, such as tingling or numbness, may be
felt in the arms and legs or over the whole body. Muscular spasms,
twitchings, and cramping pains may affect the extremities. Mental
changes, such as nervousness, excitement, and loss of inemorj^ some-
times appear. Graver cerebral symptoms suggest cerebral thrombosis
or haemorrhage. Temporary disturbances of vision are not infrequent.

It is unusual for cardio-vascular symptoms to predominate, but
palpitation is common. Coldness of the extremities may be found,
and a few patients have suffered severe neuralgic pains in them. QEdema
of the legs is sometimes present, especially late in the disease. Throm-
bosis of vessels in any part of the body may give rise to local symptoms.
Shortness of breath almost invariably forms one of the patient’s
complaints ; yet the objective distress is often slight. Vomiting occurs
in many cases, and is associated with anorexia, pain after food, and
constipation. Severe attacks of sweating are described.

The microscopical characters of the tissues post mortem are described
by Wakasugi.2

Chauffard and Troisier® record a case of erythrsemia complicated by «
ascites and gastro-epiploic thrombosis, resulting in enormous varicosity
of the superficial veins of the abdomen and thorax, similar to that
which is seen sometimes in connection with malignant disease within
the abdomen.

The fact that erythraemia is by no means uncommonly associated
with arteriosclerosis and high blood-pressure is insisted on by Monro
and Teacher. They classify types of polycythaemia as follows : —

(i) Relative: due to concentration of the blood, as in cases of severe

NEW TREATMENT

453

PREGNANCY, DIAGNOSIS OF

diaiThoea or profuse sweating ; (2) Absolute : due to excessive erythro-
blastic activity of the bone-marrow.

True polycythsemia may be either (a) Symptomatic or secondary :
met with in cases of chronic cyanosis associated with heart or lung
disease, and also in man and other animals living at high altitudes ;
or (b) Primary polycythsemia or eiy^thraemia : analogous to leukaemia,
and known by a variety of names, including “Vaquez’s disease,”
” Osier’s disease,” ” splenomegalic polycythaemia,” “myelopathic
polycythaemia,” “ polycythaemia with chronic cyanosis,” and “ erythro-
cytosis megalosplenica.”

The prognostic significance of secondary polycythaemia in cardio-
pulmonary cases has been studied by Parkes Weber, ^ who finds that
the occurrence of polycythaemia in chronic bronchitic and other similar
cases is a bad sign, and an indication of the approaching end, even
when the disease itself may appear to be less severe than it has been.
The red corpuscles under these conditions often rise to 6, 7, or even
8 million per c.mm

References. — ^Lancet 1912, ii, 1425 ; Weut. med. Woch. 1912, 2217 ;
^Presse Mid 1913, 653 ; ^Lancet 1913, i, 1015 ; ^Ibid, 1307.

PREGNANCY, DIAGNOSIS OF. (See also Blood, Examination of.)

Victor Bonney, M. 5 ., M.D,, B,Sc., F,R.C,S.

Bryden Glendining, M.S,, F.R.C.S,

Abderhalden^ has introduced a method of diagnosing pregnancy in
the laboratory by means of biochemical tests, which depend upon the
fact that in pregnancy microscopic portions of chorionic villi pass
into the maternal blood, protective ferments being developed in the
blood as a result. These ferments cause cleavage in human placental
albumin and convert it into peptone and amino-acids. He states that
they appear as early as six weeks from the date of the last menstrual
period, and continue until fifteen days after the end of pregnancy.

The following are the two methods of testing the serum : —

1. Optical Method. — This is the more difficult of the two. One c.c.
of the serum to be tested is placed in a polariscope tube with i c.c. of
a 5 per cent solution of placental peptone in normal saline. The tube
is surrounded by a water-bath at 37° C. The initial rotation is read,
and the tube placed in an incubator at 37° C. for forty-eight hours. It
is taken out at four-hourly intervals and the rotation read. A change
of 0-05° or more is considered significant of the presence of ferments and
positive in the diagnosis of pregnancy.

2. Bialysation Method. — For this test a fresh placenta is taken and
carefully washed and boiled, to free it from blood and dialysable
substances. One gram of placental albumin, after being teased into
minute pieces, is placed in the dialyser, and 1*5 c.c. of the serum to be
tested is added. The dialysers are parchment capsules prepared by
Shleicher and Schull (No. 579A), which allow peptones and amino-acids
to pass through, but not serum and placental albumin. The dialyser
and its contents are placed in a container containing 20 c.c. of distilled

PREGNANCY, DIAGNOSIS OF 454

MEDICAL ANNUAL

water. A large glass test tube makes an excellent container, the top
of which is plugged with sterile cotton-wool and placed in an incubator
at 37® C. for sixteen hours. At the end of this period of incubation,
the diah'sate is tested for amino-acids and peptones by a i per cent
solution of ninhydrin, a substance which will detect minute amounts
of peptones and amino-acids ; and if they are present, a blue or purple
colour will be given when the ninhydrin is added to boiling dialysate.

The test is a very complicated one, and can only be carried out by
those constantly in touch with modem laboratory methods. The
possible sources of error are*, (i) In the preparation of the placental
albumin, which must be free from blood and dialysable substances,
and must be tested frequently to show this ; (2) The dialysers, which
must be tested with peptones and albumin before the test is made ;
(3) If the serum is taken from a patient while digestion is in process,
it may possibly contain enough amino-acids to give a positive reaction
without the addition of placental albumin. This would be noticed
in the controls to the actual test.

Schlimpert and Hendry^ have reported 79 cases wdiich they have
tested wdth very careful technique by Abderhalden’s method. Thirty-
nine non-pregnant cases all gave a negative reaction. Forty w’ere
pregnant, and in all these the reaction was positive at the following
dates : one to three months, 8 cases, the earliest of which was four
days after cessation of menstruation ; four to six months, 2 cases ;
seven to ten months, 18 cases ; during labour, 2 cases ; during the
lying-in, 10 cases. The latest date in the puerperal cases was one
•which gave a faint reaction on the thirteenth day after labour.

Gutman and Druskin® give their experiences of the test in 106 cases,
of w^hich 27 were non-pregnant and 79 were pregnant. Of the 27 non-
pregnant cases, 26 gave a negative result, and i was positive. Of
the 79 pregnant cases, 78 gave positive results and i was negative.

Stauge^ examined 78 cases, and obtained correct results in all —
73 pregnant cases giving positive, and 5 non-pregnant cases negative,
results'.

Jaworski and Szymanowski® have examined 70 cases, with positive
results in all the 35 cases of uterine pregnancy examined ; they also
obtained positive results in puerperal cases up to the fourteenth day
after labour. The results were positive in three cases of extra-uterine
gestation ; and negative in puerperal cases after the fourteenth day,
in three cases of old pelvic hsematocele, and in all cases which were
after^vards proved not to be pregnant.

Schiff® has tested a series of 49 cases. He obtained positive results
in 33, only 31 of which were pregnant, the two incorrect ones being
a case of bleeding at the menopause and one of myoma of the uterus ;
in both these the blood had haemolysed before separation of the
serum. He obtained negative results in 16 cases, all of which were
correct. The earliest pregnancy in which he obtained a positive
reaction was fourteen days after cessation of the menstrual period.

Elder' examined 12 cases, in all of w'hich he obtained correct

NEW TREATMENT

455 PREGNANCY, TOX/EMIAS OF

results. Five cases, two of pregnancy and three of retained placenta,
gave a positive reaction, the rest being negative.

Mensuration. — Spalding® considers that abdominal measurements
are of value in estimating the degree of maturity of the unborn child ;
and that it is possible to estimate wuth considerable accuracy the
probable week of pregnancy from accurate measurements of the height
of the fundus above the symphysis taken with a tape measure.

McDonald® also describes a similar method. He measures with a
centimetre tape applied to the abdominal wall, and finds that 35 cm,
is the usual height at full term, and that it grows in height 3*5 cm.
every lunar month. He makes the following rule : The duration of
pregnancy in lunar months equals the height of the uterus in centi-
metres divided by 3*5.

References.— med. Woch. 1912, 2160 ; -Mimch. med. Woch. 1913,
681 ; ^Med. Rec. 1913, ii, 99 ; ^Munch.'med. Woch. 1913, 10S4 ; /din.

Woc/i. 1913, 922 ; ^Munch. med. Woch. 1913. 1197 5 ’^Wien. Jilin. Woch. 1913,
696 ; ^Joitv. Amer. Med. Assoc. 1913, ii, 746; Kdmer. Med. 1913, i, 226.

PREGNANCY, ECTOPIC. Victor Bonney, M.5., M.D., B.Sc., F.R.C.S.

Bryden Glendining, M.S., F.R.C.S.

Huffman^ draw’s attention to the frequent occurrence of some
abnormality of the Fallopian tube, e.g., accessory tubes, accessory ostia,
small cysts at the abdominal ostia, etc., in cases of tubal pregnancy.
From the study, both macroscopic and microscopic, of many specimens,
he considers that there is ample support for the theory that ectopic
pregnancy is caused by imbedding areas being present in different
situations through mal-development of the Milllerian duct. Normally
the imbedding area is in the uterus only.

Green^ advises Direct Blood Transfusion in the treatment of severe
cases of extra-uterine gestation. He thinks that it may be used with
advantage as soon as the hcemorrhage is stopped, and w’hile the patient
is still under anaesthesia. He uses the radial artery of the donor of the
blood, and the median basilic vein of the patient, connecting them by
an Elsberg cannula. Cobb® has studied 137 cases, and concludes that
Immediate Operation is the best treatment, delay of any kind, even
for transfusion, being unjustifiable and dangerous. With proper
technique, and the use of intravenous saline solution, the operation
mortality will be very low^

References. — '^Surg. Gyn. and Obst. 1913, i, 54S ; ^Bost. Med. and Surg.
Jour. 1913, i, 270 ; ^Ann. Surg. 1912, ii, S35.

PREGNANCY, SYPHILIS AND. {See Syphilis.)

PREGNANCY, TOXEMIAS OF.

Victor Bonney, M.5., M.D., B.Sc,, F.R.C.S.

Bryden Glendining, M.S., F.R.C.S.

Albuminuria. — Williamson^ thinks we are justified in concluding
that a condition of acidosis is constantly found in pregnancy toxaemia
of a severe type, but not in cases of chronic nephritis, even when the
symptoms are severe ; also that the onset of acidosis in a case of chronic

PREGNANCY, TOX.€MIAS OF 456

MEDICAL ANNUAL

nephritis ^vith pregnane}?- means that toxaemia has been added to the
existing lesions. In pregnancy toxaemia, chloroform should never be
administered, because its action is to render the existing lesions more
grave and to increase the acidosis. Ether given by the open method
is the safest aniesthetic. Calomel as an aperient, and vaginal douches
of mercurial antiseptics, should be avoided, as the lesions in the liver
and kidneys in mercurial poisoning are of the same nature as those of
pregnancy toxaemia ; and it is probable that mercury in small doses
will increase the gra-vity of the lesions already existing. In all cases
where an acidosis is present, intravenous infusion of a solution of
Sodium Bicarbonate or Sodium Acetate should be practised. Glucose
given in solution by the mouth or rectum is valuable in preventing
excessive fat metabolism. When a pregnant woman with chronic
nephritis shows signs of acidosis, the Uterus should be emptied with-
out delay, for with a previously damaged kidney the prognosis of
pregnancy toxaemia is very grave.

Vomiting of Pregnancy , — Sergent and Lian^ consider that the
ordinary vomiting of pregnancy is a “ villo-toxsemia,” that pernicious
vomiting is due to insufficient suprarenal secretion. They quote six
cases in which immediate and marked improvement followed treatment
by Suprarenal Extract or Adrenalin after all other therapeutic measures
had failed. They think that pregnancy should never be ended for
pernicious vomiting until a trial has been given to this method.

Whitridge Williams^ divides the vomiting of pregnancy into three
classes — neurotic, toxaemic, and reflex, of which the neurotic is the
most and the reflex the least frequent type, while the toxaemic is the
most serious. He thinks that the underlying factor in all cases is
probably an imperfect reaction on the part of the mother to the growing
ovum ; in most cases this is only a predisposing cause, and the exciting
factor is a reflex or neurotic influence, removal of which brings cure.
He considers that the significance of a high ammonia coefficient is not
specifier ; it may be a manifestation of toxaemic vomiting, of starvation
following neurotic vomiting, or of an acidosis due to any cause ; it
should be regarded as a danger signal, while the differentiation between
the various types can only be made after careful clinical observation.
If improvement does not promptly follow appropriate treatment,
the existence of toxaemic vomiting should be assumed and abortion
immediately induced. The best method of emptying the uterus in
primigra\ddae, and the one -which causes least shock, is Vaginal
Hysterotomy, in Williams’ opinion. Nitrous-oxide gas or ether should
be used in preference to chloroform for anaesthesia.

Eclampsia. — Haultain'* gives the history of seven cases treated by
Yeratrone (a Parke Davis preparation of the alkaloids of veratrum
viride for subcutaneous injection). Four cases were in primigravidae,
all of whom recovered ; three were multiparae, one of whom died, one
recovered but became maniacal, while the third recovered. This last
case was of considerable interest, in that she was only six months
pregnant, and after treatment pregnancy went on normally to full

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457 PREGNANCY, TOX>EIVIIAS OF

term. The dose is i c.c. injected subcutaneously. The results were
noticeable as soon as five minutes after the injection ; they consist of
marked lowering of the blood-pressure and slowing of the pulse. If
the pressure rises again, another injection should be given. The
author advises a further trial of this remedy, which is only empirical.

Coughlin® describes the' treatment of eclampsia in three cases by
Yeratrum Yiride, which he considers a very valuable drug. It may
be given by hypodermic injection or by the mouth, the former method
being preferable. Its action is to lower the pulse-rate and tension, and
to control the convulsions. He advises that this treatment be com-
bined with rapid delivery whenever possible.

Wallace® describes the treatment of the convulsion in two cases of
eclampsia by intrathecal injections of a 25 per cent solution of
Magnesium Sulphate. The amount injected depends on the weight of
the patient, i c.c. being allowed to every 25 lb. of body weight. The
points noticed were the freedom from convulsions after the injection,,
in one case for seven hours and the other for four hours, seven and six
fits respectively having occurred prior to the injection; and, both
women had living children, the second case being a severe one where
a live child would not have been expected unless the convulsions had
been stopped by some means.

Halliday Cioom’ considers Caesarean Section to be the most satisfac-
tory method of rapid delivery ; if labour is in progress and the cervix
slightly dilated, he considers the vaginal the better route, and. advises
that delivery be completed by version rather than by forceps. If
labour has not started and pregnancy is near term, he prefers the
abdominal route, which is no more dangerous in suitable surroundings.
For post-partum eclampsia when all methods of treatment fail, the
fits continue, and the patient is in great danger, he strongly recommends
Decapsulation of the Kidneys.

Peterson® advocates Emptying the Uterus as the best treatment
of eclampsia. He has examined the records of a large number of
cases, and finds that of 615 treated by prompt delivery the maternal
mortality was 1 5*9 per cent, while in 390 treated expectantly it was
28-9 per cent. He considers that when the uterus is emptied imme-
diately or very soon after the first convulsion, the maternal mortality
is still lower. He advises the operative procedure which will empt}^
the uterus in the quickest time, with least trauma and shock to the
mother, i.e.. Caesarean section.

Shears® claims to have obtained good results by treating cases of
toxaemia in pregnancy by free use of Oxygen, either by inhalation or
subcutaneously. He gives no detailed results.

Dermatitis. — Wolffs® records the case of a woman suffering from,
pruritus and dermatitis during pregnancy, which he treated by
intravenous injection of 8 c.c. of the patient’s serum which had
previously been inactivated. The irritation improved considerably,
and some of the rash disappeared ; but the patient had a relapse, which
he treated by intramuscular injection of 10 c.c. of serum obtained

PREGNANCY, TOXy^EMIAS OF 458

MEDICAL ANNUAL

from a healthy patient fom'teen days after labour. The serum was
inactivated before injection. The result was very marked, and in four
days all irritation had completely disappeared.

References. — '^Lancet, 1913,!, 1363; ^Presse Med. 1912, 1033; ^Glasg.
Med. Jour. 1912, ii, 401 ; ‘^Edin. Med. Jour. 1913, i, 313 ; ^Med. Rec. 1912,
ji, 3S6 ; ^Lancet, 1912, ii, 1574 ; "^Med. Press and Circ. 1913^ i> 114 J ^Amev.
Jour. Obsiet. 1913, it 201; ^Med. Rec. 1913^ t 66; ’^^Berl. him. Woch. 1913,

i66i.

PROSTATE, DISEASES OF. J. W, Thomson Walker, M.B., F.R.C.S.

Simple Enlargement. — Cuthbert Wallace^ discusses some conditions
simulating prostatic hypertrophy. Prostatic symptoms may be
produced by enlargement of the organ which is difficult to detect until
the bladder is opened and a bimanual examination made. Antero-
posterior angling of the prostatic urethra in middle-aged and old men,
without enlargement, may cause obstruction. The following condi-
tions have been described as giving rise to symptoms imitating those
of prostatic enlargement : (i) Induration of the internal meatus ;

(2) Primary atony of the bladder muscle ; (3) Secondary failure of the
muscle due to inflammation ; (4) Fibrosis of the muscle due to old
age ; (5) Want of correlation between the sphincter and the detrusor ;
(6) A loss of sensibility of the mucous membrane ; (7) Chronic prosta-
titis and post-urethral bar formation ; (8) Atrophy of the prostate ;
(9) Perverted prostatic secretion acting on the bladder; (10) Failure
of the extraspinal bladder centre. The author concludes that even
when a bimanual examination discovers no enlargement, the cause of
the trouble may still lie within the prostate. No error of micturition
should be assigned to a failure of nerve or muscle until all mechanical
defects have been excluded. Bending of the prostatic urethra is the
cause of the difficult micturition in some cases, which can be cured by
a simple operation.

H. Cabot^ favours the view that the pathological condition in simple
enlargement of the prostate is not a hypertrophy but the formation of
adenomatous tissue arising in certain portions of the gland and re-
placing the normal tissue wholly or in part. He agrees with Lorvsley’s
division of the prostate into a posterior, a median, and two lateral lobes,
with the occasional persistence of an anterior lobe, and the frequent
occurrence of detached groups of glands such as the subcervical group.
The adenomatous masses arise from the median and lateral lobes,
occasionally^ from the subcervical glands and a persistent anterior lobe.
There is no evidence that they ever arise from the posterior lobe. The
masses occupying the lateral lobes are covered posteriorly by the pos-
terior lobe, and do not here come in contact with the capsule. Laterally
they lie against the true capsule or sheath of the prostate. Superiorly
they abut upon the median lobe, and in the absence of its development
upon the muscular structures of the bladder-neck. Mesially they are
covered only by mucous membrane and by the stretched and atrophied
capsule of the prostate, from which they cannot be separated by
dissection. The mass arising from the median lobe is covered pos-

NEW TREATMENT

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PROSTATE

teriorly by the posterior lobe. In the operation of enucleation the
adenomatous masses in the lateral and median lobes are shelled out
from the capsule of the prostate on the side, from the muscular structure
of the bladder-neck above, and from the posterior lobe, the old so-called
surgical capsule, below. The perineal operation described by Young
is termed conservative, the object being to preserve the ejaculatory
ducts and avoid injury to the structures involved in the nervous
mechanisms pertaining to potency.” If the lobes are truly enucleated,
as Young states, the mucous membrane of the urethra must also be
removed, as it cannot be dissected oH the lobes even outside the body.
What does take place is the enucleation of greater or smaller portions
of these lateral and median masses from within the masses themselves,
the amount of adenoma left behind depending upon the lines of cleavage
within the mass and the experience and dexterity of the operator.
The adenomatous tissue left behind reproduces more or less exactly the
form of the obstructing tumour present before the operation, and it
remains largely a matter of accident whether the relief to the patient
is large or small. The avoidance of the ejaculatory ducts is extremely
problematical. Having regard only for the functional results, Cabot
believes that the Suprapubic route is far superior. By this method it
can be declared with certainty that if the patient survives the operation
the function of the bladder will be restored practically to normal. By
the perineal method, muscular control is jeopardized, particularly in
the case of large masses ; and a certain number of cases of incontinence,
more or less partial, are almost certain to follow. Fistulae of various
kinds occasionally result, those communicating with the bowel being
the least common but the most serious.

E. S. Judd^ also prefers the suprapubic to the perineal route, and
advocates careful preparation of the patient before operating. The
first step is to relieve him of the residual urine, and treat cystitis if it
exists. The urine retained in the bladder should be withdrawn grad-
ually, keeping it empty for a longer period each day until no bad effects
are apparent. In many instances it will require several weeks to carr^^
this out. In about three-fourths of the cases the requisite drainage
has been accomplished by a permanent catheter introduced into the
bladder through the urethra. In the remaining fourth it was necessary
to make a preliminary suprapubic stab-drain, because introduction of a
catheter was impossible or uncomfortable. The second step consisted
. in the removal of the prostate. According to this author, the chief
disadvantage of the suprapubic method is the length of time required
for the urinary fistula to heal, owing to infection of the suprapubic
space. “ It has not been uncommon to see these cases drain for weeks
or even months, or terminate badly on account of extensive infection.”
On this account he closes the wound in the bladder completely and ties
.a catheter in the urethra, or introduces a small tube at the upper end
of the suprapubic wound. In the first case, a two-way catheter is
used, with constant irrigation, for twenty-four hours, or a single-bore
catheter is used, and a nurse syringes the bladder every few minutes.

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A. E. Rockey^ also supports the suprapubic route, and uses spinal
ancEsthesia with stovaiii. He has totally abandoned irrigation at an'd
after operation. After enucleation of the gland, the author stitches
the bladder to the muscle and fascia of the abdomal wall, so that “ the
bladder wall is suspended against the abdomal wall in such a manner
that the edges of the vesical incision turn inward, giving a valve which
much facilitates subsequent healing.'’ He uses a drainage tube of
I in. diameter, believing that very large tubes are unnecessar3^

P. J. Freyer® reviews his experience in suprapubic prostatectomy to
the end of 1912. There were 1036 cases, the age varying from 49 to
90 years, with an average of 69^ years. The prostates removed ranged
from J to 17 oz. in weight. There wxre 57 deaths, or 5J per cent.
In one case the bladder remained flaccid after the operation, and
“'seems to have been completely paralyzed by the extreme over-
distention by the urine before the catheter was employed.” The
mortality has gradually diminished from about 10 per cent to a little
over 4-i- per cent in the last 400 cases. In igo cases, stones, usually
phosphatic, were present in the bladder. Among these there %vere 16
deaths, or 8*42 per cent — nearly double that in the cases uncomplicated
wdth stone. In 55 cases, Fullerton’s® mortality was 7*2 per cent. The
most serious complications and sequelae were haemorrhage, shock,
hypostatic congestion of the lungs, sepsis, epididymitis, suprapubic
flstula, phosphatic deposit on the suprapubic wound, stone in the
bladder, uraemia, stricture of the urethra, incontinence of urine, peri-
renal abscess, haematemesis, ventral hernia, and mental symptoms.

Wilms 7 describes his method of Perineal Prostatectomy with lateral
incision. He employs either local or spinal anaesthesia, using novocain
for the latter after injecting 20 c.c. of normal saline with 4 or 5 drops of
adrenalin in order to hinder its rapid distribution. The patient is
placed in the lithotomy position, the bladder is filled, and Young’s
prostatic retractor introduced. The scrotum is drawn to one side, and
an incision made parallel to the descending ramus of the pubic bone,
extending forwards to within ij to 2 cm. of the symphysis. The skin
and superficial fascia are cut through, and the point at which Young’s
retractor enters the prostate is searched for with the finger. This is
very easily found, as it lies only about 2 cm. from the surface. Dressing
forceps are pushed alongside the instrument through the prostatic
capsule and the blades separated, so that an opening is made through
which the finger passes, and the prostate gland is enucleated in similar
manner to the suprapubic method. The left lobe is first separated,
then the retractor is removed, and the assistant presses suprapubically
on the distended bladder while the right lobe is separated. Forceps
are now introduced, and the gland is withdrawn, usually in a single mass.

Hartmann® records 43 cases of subtotal perineal prostatectomy,
with 8 deaths and 35 cures. In 2 cases death was due to secondary
haemorrhage, and in 3 to pulmonary complications. Orchitis occurred
ill 10 cases, -and rectoperineal fistula in 2. Late results were known in
27 cases. In 17 there were no urinar}^ symptoms ; in 9 there was either

NEW TREATMENT

461

PROSTATE

slight cystitis or incomplete retention. In transvesical prostatectomy
Hartmann sutures the margin of the bladder wound to the muscle and
fascia of the abdominal wall to avoid retraction of the bladder and
urinary infiltration. In 53 cases there were 44 cures and g deaths, i due
to spinal anaesthesia, i to anuria, 4 to pulmonary complications, 2 to
urinary infiltration, and i to pyelonephritis. Late results were obtained
in 29 cases ; of these 24 were completely cured. The end-results of
transvesical prostatectomy were therefore better than those of perineal.

Small Prostatic Bars and Contracture of the Orifice des-
cribes a new Punch Operation. The instrument consists of " an outer
tube about 18 cm. long, with a coude curve at its inner end and a
urethroscopic disc at the other, containing a part on which an external
urethroscopic light can be attached. Near the inner end on the under
surface a large deep fenestra is provided. Within the instrument is a
second tube with a sharp cutting inner end made of steel, which
when pushed home can excise anything appearing inside the outer
tube. The object of this instrument is, when pushed through the
urethra into the bladder, to engage the median bar in the fenestra, and
then to excise it by means of the inner cutting-tube, while observing
the operation through the inner tube illuminated with the external
urethroscopic lamp.’' One cut is usually not sufficient, and lateral
cuts are made on each side. When the cutting inner tube is removed,
the bladder is washed out tlirough the outer tube until clear of clots.
The obturator is introduced and the instrument withdrawn. A
way catheter is then introduced into the bladder, and continuous irriga-
tion kept up for twenty-four or forty-eight hours. Sometimes the
tubes become plugged with clots, which have to be removed by a
syringe. The author has performed the operation on 51 cases of simple
bars or contracture of the prostatic orifice ; median bar with diverticu-
lum, 4 cases ; bar with vesical calculus, ii ; small lobe obstruction after
prostatectomy, 20 ; small lobe with trigonal obstruction, 3 ; small
bar associated with spinal disease, 4 ; obstruction associated with
cancer of the bladder and prostate, 9. The immediate results, according
to the author, were satisfactory in all cases. In a few trouble was
experienced on account of plugging of the catheter with blood-clot,
but in no case was the haemorrhage alarming. The remote results,
“ even in cases of complete retention of urine and catheter life are
entirely satisfactory.”

Cancer. — R. J. Willan^^ finds from a study of 33 cases that the average
duration between the onset of symptoms and the first consultation
with a surgeon was fourteen months and a half. The average age was
61. The onset symptom was increased nocturnal frequency of micturi-
tion in 40 per cent, and gradual obstruction to urination in 30 per cent.
Pain was variable and not characteristic. Urinary obstruction was a
marked feature, complete retention being present in 72 per cent and
partial retention in 24 per cent. Haematuria was not common. On
rectal examination, 70 per cent showed hard nodules with fixity of the
gland. The average duration of the disease from onset of symptoms

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MEDICAL ANNUAL

to death was twenty-eight months. The treatment recommended
when there was no residual urine was the administration of a Urinary
Antiseptic and Opium w’hen necessary. If residual urine is present,
Catherization should be commenced.. If there is obstruction, or if
catheter life is intolerable, permanent Suprapubic Drainage should be
established.

Eugene Fuller^^ discards suprapubic enucleation as unsuitable for
the great majority of cancer cases, and performs a combined suprapubic
and perineal operation by which he removes a “ boat-shaped " section
of the growth. The patient is placed in the lithotomy position, and
the left forefinger introduced into the rectum. A long-bladed, straight,
blunt-pointed bistoury is passed through the perineal opening along
the prostatic urethra into the bladder. Guided by this finger the
prostate is cut backwards towards the bowel in the middle line. The
knife is turned to the right, and made to curve forward, cutting a wedge
like one-half of a boat out of the right side of the prostatic mass. It is
then returned to the middle line and a similar wedge is cut out of the
left side of the prostate. The operation is finished by cutting wdth
scissors from the perineum, and drainage tubes are placed in both
suprapubic and perineal wounds. The operation is not radical, but it
relieves the prostatic obstruction and prolongs life.

Chronic Prostatitis , — draws attention to the r61e of the
prostate and seminal vesicles in chronic toxcemias and remote infections.
Chronic prostatitis and seminal vesiculitis ^ are extremely common
diseases ; they may exist without producing symptoms for years, and
then show themselves as a danger seat when the patient marries or
becomes the subject of chronic rheumatism. The original etiology of
these cases is not always gonorrhoeal. Many arise from descending
bacterial infections, and the infection may also reach the prostate from
the rectum as a result of proctitis, ulcer, haemorrhoids, etc., but more
commonly still from long-continued masturbation. On rectal examin-
ation the prostate is very little enlarged. It is smooth and indurated,
and may show slight irregularities, with adhesions to the rectum and
pelvic wall. The seminal vesicles are usually affected similarly. The
local symptoms are often slight, amounting to a slight fullness and dis-
comfort. The nervous S 3 nnptoms are often so remote that the prostate
is not suspected. They may take the form of lumbago, sciatica, vague
pains in the back, hips, thighs, perineum, groin, or soles of the feet.
In operating on the prostate and seminal vesicles for this condition.
Young uses the usual inverted V-shaped cutaneous incision in the
perineum, and exposes the prostate as if for perineal prostatectomy.
Next, instead of incising the membranous urethra, the long retractor is
pushed down into the bladder, opened, and traction made ; and the
posterior surface of the prostate, and by further traction the seminal
vesicles, are exposed. If the vesicle is surrounded by adhesions these
are freed, and the vesicle either opened by one or more incisions or by
removing a portion of its posterior surface. Resection and extensive
incision are unnecessary and undesirable except in tuberculosis, where

NEW TREATMENT

463

PROTEINURIA

operation is usually contraindicated. The prostate is dealt with by
incision or by excision of portions, depending on the extent of the
disease, care being taken to preserve the floor of the urethra and
ejaculatory ducts, and not to open the urethra. {See also Seminal
Vesicles.)

References. — Jour. 1913, July, 209 ; ^Suvg. Gyn. and Ohst. 1913,
ii, 213 ; ^Ihid. i, 379 ; ^Ibid. 424; ^Lancet, 1913, i, loiS ; Med. Jour.

1913, i, 332 ; "^Munch. med. Woc/i. 1912, 2548 ; ^Reps. Hartmann's Clinics.
4th Series, 1912, loi (Snrg. Gyn. and Ohst. Abstr, 1913, i, loi) ; ^Jonr. Amer.
Med. Assoc. 1913, i, 253 ; Med. Jour. 1913, ii, 60 ; '^^Ann. Surg. 1912,

ii, 738 ; '^^Jour. Amer. Med. Assoc. 1913, ii, 822.

PROTEINURIA. Francis D. Boyd, M.D.

A number of important communications have appeared on the
subject of Bence-Jones* proteinuria. An exhaustive chemical study
of Hopkins and Savory^ showed that the body was not, as generally
believed, an albuminose, but a true protein, yielding the characteristic
amino-acids on hydrolysis. The theories as to the origin of this protein
are numerous, but the most important of these seek its derivation :
(i) From the protein of the tissues or blood ; (2) Specifically from the
disease of the bones ; and (3) As a product of abnormal protein meta-
bolism, either endogenous or exogenous. The great majority of the
cases in which this body is found in the urine have been instances of
multiple myelomata, though not all sufferers from this disease have
exhibited proteinuria, and in isolated instances it has been found
associated with other pathological conditions such as leukaemia,
chloroma, lymphosarcoma, myxoedema, and carcinomatous metastasis.
The specific relation of the Bence-Jones protein depends upon the
relative stability of its compounds with neutral salts at the boiling
temperature, and their instability at lower temperatures. As Boggs
and Guthrie^ point out, it is important, in applying the heat and acid
test to the urine for the detection of the protein, that it should be
heated slowly, in order that differences of temperature in the deter-
mination of precipitation may be apparent. Should coagulation begin
below the boiling point, more careful examination for detection of
unusual protein is indicated. If precipitation occurs below the boiling
point, careful notes should be made of any tendency towards clearing
on boiling the specimen, and the test repeated with the aid of a water-
bath and thermometer. Confirmatory tests are made by treating the
specimen with a few drops of 25 per cent nitric acid : the initial
turbidity in the cold is increased when approaching 60° C., and clears
up more or less completely at 100° C., falling out again as the specimen
cools. In a case observed by Henderson,® the saturated protein in
aqueous solution coagulated at 50° C. For further confirmation,
another specimen is treated with two volumes of saturated solution
of ammonium sulphate, when a voluminous precipitation occurs, some-
times quite slowly. These tests are sufficient to establish the presence
of the Bence-Jones protein. A striking feature in some of the cases was
a diminution in the chloride excretion.

PROTEINURIA

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MEDICAL ANNUAL

Notwithstanding the paradoxical incidence of Bence-Jones’ protein-
uria in hone -marrow disease, it seems probable that the marrow is in
some way concerned in its production. Boggs and Guthrie’s paper^
in the Johns Hopkins Hospital Bulletin is well illustrated by Ar-ray
photographs of metastatic nodules in the skull, pelvis, and long bones.
[See Plate XXXV 1),

Groves-^ recounts a very unusual case of multiple myelomata with
numerous spontaneous fractures, where proteinuria was present. The
case is remarkable in respect that the history persisted over twelve
years, and when observed, the patient appeared to be in good health,
the disease being quite stationary. As a rule in these cases the prog-
nosis is utterly bad, many sufferers having only survived the recogni-
tion of their complaint by a few months. For six years this patient
had a long history of bone-breakings, seven times fracturing one or
other of the long bones, in addition to developing tumours of the jaw,
metacarpus, and tarsus. For the subsequent five years there had been
no further development either of fractures or tumours. It is interesting
to note that the fractures, although brought about by the development
of tumours, always united firmly. [See Plates XXXVII, XXXVIIL)

The morbid anatomy of multiple myelomata and its associations
with proteinuria are fully discussed by Shennan.®

References. — ^Jonr. of Physiol. 1911, 1S9 ; ^ Johns Hop. Hosp. Bull.
191-2. 353. and Amer. Jour. Med. Sci. 1912, ii, 803 ; '^Lancet, 1913. i^ 522 ;
K-inn. Surg. 1913. i, 163 ; '^Edin. Med. Jour. 1913, i. 321.

PSEUDO-GLANDERS. [See Glanders.)

PSORIASIS. E. Graham Little, M.D., F.R.C.P.

Knowles^ sets out to disprove the hereditary causation of psoriasis,
and states that in nine years, during which he has given attention to
this point, only six cases of family inheritance have been made out
to his satisfaction.

Treatment. — ^B rocq and Simon^ say that, internally, there is no
specific, but Arsenic, Mercury, Iodide of Potassium, Thyroid Extract,
Copaiba, Sandalwood Oil, and Turpentine have all proved useful.
Vegetarian Diet occasionally yields excellent results ; externally, when
the skin is much inflamed. Starch or Gelatin Baths, lasting tAventy
minutes. Occlusive Dressings with rubber tissue should be used, and
Benzonaphthol Ointment, beginning with 1-40 strength, progressiA'ely
increased. When the patient must conduct his OAvn treatment,
Sulphur or Alkaline Baths should be gh^en daily, immediately followed
by rubbing in the following ointment : —

U 01. Cadini part, c | Glycerin. ^Vinyli part, xch’

Sapon. Moll. q.s. (for Acid. Salicyl. part, iij

emulsification) 1 Essent. Caryoph. part, x

If this should prove too irritable, the oil of cade and salicylic acid
should be reduced. Flannel combinations should be used, so that the
oil saturates the fabric and the patient constantly steeps in it. Where

PLATE XXXVI IL

CASE OF MULTIPLE MYELOMATA-

/•Vv. C, — 'iklas^iani of left It” niicl foot. 'J'lie same case as FI^s. A i
'I'wo fiacturcs, 1901-1905. Growths in tibia, fibula, and os calci

E. If,

rind

MEDICAL AN SEAL, ni f

PSORIASIS

NEW TREATMENT 465

the smell of this application forbids its use, the following may be
substituted : —

R Acid. Salicyl. gr. viij I Vaselini 3 ^

Acid. Pyrogal. gr. xvj |

■The urine must be watched for evidence of pyrogallic poisoning.
Calomel ointment from 1-50 to 1-20 may be used, salivation being
watched for. Where the patient can be continually kept under
observation, Ghrysarobin is the most efficient application (but not on
the scalp), and for small areas this ointment may be recommended : —

R Chrysarobini 3j I Vaselini gv

Acid. Salicyl. gr. xlv |

The chrysarobin in this formula may be increased gradually to gj,
Montgomery^ dwells on the advantages of Baths, and especially
recommends the following combination : the patient soaks for ten to
fifteen minutes in a warm bath to which an ounce of saturated
solution of Potassium Permanganate is added ; he is thoroughly dried,
and the following thin paste is applied : —

R Amyli Liq. Plumbi Subacct. part, iv

Talci aa part, xl Liq. Picis Carbonis part, xx

Glycerini part, xx Aq. part, cc

Gumm, Arabic. part, j

Maceration by means of impermeable coverings is especially useluLin
chronic thickened patches. The following paste, applied to the part,
which is then covered wdth oil-silk kept in position with plaster, is
especially active : —

R Acid. Salicyl. part, x Sapon. Virid.

Chrysarobini Lanolini aa part. xx\^

01, Rusci aa paid, xx

Or the followdng lotion : —

R Liq. Plumbi Subacct. part, xx | Li<i. Picis Carbonis pa-rt. c

One drachm of this is added to a pint of water; lint soaked in this
solution is applied to the parts, which are covered with oil-silk and
left so all night.

Ravogli^ has come to adopt the '' nervous origin ” as an explanation
of psoriasis, and prefers the treatment by arsenic. Salvarsan he has
found useless in the few cases he has tried. Pic habitually uses sub-
cutaneous injections of Cacodylic Acid (10 per cent), one injection
two or three times a week'. He recommends for local application the
followdng ointment : —

R Hydrarg. Precip. Alb. gr. v-x | Acid. Carbol. gutt. vj

Bismuth. Subcarb. I Petrolat. Alb. Sj

Zinci Osidi aa 5^3 '

When arsenic disagrees, or ceases to produce effect, Potassium
Iodide should be substituted in combination with the salve named
above. — [The writer has had some further encouraging experience
with Enesol injections, given in 2 c.c. doses intramuscularly every

PSORIASIS

466

MEDICAL ANNUAL

second day for fifteen to twenty injections. No mercurial or arsenical
intoxication has resulted from its use, and it can be recommended. —
E. G. L.] [See also Skin, General Therapeutics of.]

References. — ^Jour. Amor. Med. Assoc, 1912, ii, 415; ^Med. Press and
Circ, 1912, ii, ^80 ; '^Jour. Amev. Med. Assoc. igi2, ii, 520 ; ^Jour, Cut. Dis.
rgis. 250.

PSYCHO-ANALYSIS. Bedford Pierce, M.D., F.R.C.P.

At the International Congress of Medicine, 1913, C. G. Jung, of
Zurich, stated his reasons for not accepting Freud’s teachings in I'espect
to the etiological significance of infantile sexual trauma in the production
of the neuroses. This disclaimer by one of the chief exponents of
psycho-analysis provoked much interest. Several who joined in the
discussion, re -asserted their acceptance of Freud’s theory in its entirety,
and stated that its application in therapeutics was of great value.
Others, however, welcomed Jung’s pronouncement as freeing psycho-
analysis from an etiological assumption that was fanciful and far-
fetched.

After stating that the original theory that hysteria and the related
neuroses take their origin in trauma or shock of a sexual character in
early childhood was given up by Freud fifteen years ago, and that
many patients who had related an early traumatic event had invented
the story of a so-called trauma, Jung dealt with Freud’s “ fixation
theory.” ” From the standpoint of this theory, the neurotic appears
to be entirely dependent upon his infantile past, and all his troubles in
later life, his moral conflicts, and his deficiencies, seem to be derived
from the powerful influences of the past.” The therapy is in full
accordance wdth this theory; its ” chief concern is conceived to be
the unravelling of this infantile fixation, which is understood as an
unconscious attachment of the sexual ‘ libido ’ to certain infantile
phantasies and habits.” . . ” It is worth while to demand the
nature of the proofs of this infantile fixation.” And after discussing
the question he states, ” I have to state that a purely sexual etiology
of neurosis seems to me much too narrowL I base this criticism upon
no prejudice against sexuality, but upon an intimate acquaintance
with the whole problem. Theiefoie I propose to liberate the psycho-
analytic theory from the purely sexual standpoint.” Jung con-
siders psychological phenomena as manifestations of energy, which
he terms “ libido,” desire, but not confining the term to sexual desires.
He considers that the neuroses arise through a failure of adaptation
producing repressive changes. ” Therefore I no longer find the cause
of the neuroses in the past, but in the present. I ask what the necessary
task is -which the patient will not accomplish. ... A sensitive and
somewhat disharmonious character will meet special difficulties. . .
For the neurotic there is no established way to his aims and tasks. . .
The way of adaptation being blocked, the biological energy we call
libido does not then find its suitable outlet or activity, and therefore
replaces the modern and suitable form of adaptation through an abnor-
mal, i.e., primitive one. ... It is perfectly true, as Freud states, that

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467

PUNCTURE FLUIDS

infantile phantasies determine the form and further development of
the neuroses, but this is not etiology. Even when we find perverted
sexual phantasies of which we can prove the existence in childhood,
we cannot consider them of etiological significance. To sum up : I
cannot see the real etiology of a neurosis in the various manifestations
of infantile sexual development and their corresponding phantasies.
The fact that they are exaggerated and put into the foreground in
neurosis is a consequence of a stored-up energy or libido. The psycho-
logical trouble in neurosis, and neurosis itself, can be considered as an
act of adaptation that has failed. This formulation might reconcile
certain views of Janet’s with Freud’s view that a neurosis is — under a
certain aspect — an attempt at self-cure ; a view which can be, and has
been, applied to many diseases. Here the question arises whether it is
still advisable to bring to light all the patient’s phantasies by anal3^sis,
if we now consider them as of no etiological significance. Psycho-
analysis hitherto has proceeded to the unravelling of these phantasies
because it considered them as etiologically significant. My altered
view concerning the theory of neurosis does not change the procedure
of psycho-analysis. The technique remains the same. We no longer
imagine we are unravelling the final root of the disease, but we have to
haul up the phantasies because the energy which the patient needs
for his health, i.e., for his adaptation; is attached to the sexual phan-
tasies. Through psycho-analysis you re-establish the connection
between the conscious and the libido in the unconscious. Thus you
restore this unconscious libido to the command of conscious intention.
Only in this way can the formerly split-off energy become again
applicable to the accomplishments of the necessary tasks of life.
Considered from this standpoint, psy^cho-analysis no longer appears to
be a mere reduction of the individual to his primitive sexual wishes,
and it becomes clear that psycho-analysis, rightly understood, is a
highly moral task of an immense educational value.'*

Alexander Neuer^ alludes to the amazing change of front of the
Freudian school, criticizes Jung’s use of the word “libido,” and
attempts to show that he is indebted to Adler and Macdow for many
of his views. His article sets forth plainly the confusion at present
existing in the ranks of the psycho-anatysts.

Reference. — ^Joiir. Ment. Sci. 1913. Oct.

PUDENDAL GRANULOMA. {See Granuloma, Pudendal.)

PULMONARY EMBOLISM. {See Lung, Surgery of ; Operations,
Complications following.)

PULMONARY TUBERCULOSIS. {See Tuberculosis, Pulmonary.)

PUNCTURE FLUIDS. {See also Cerebrospinal Fluid.)

Oskar C. Gritner, M.D.

A good review of the clinical examination of puncture fluids is given
by Janowski,^ whose conclusions on its practical value, however, are
somewhat pessimistic. The variations of specific gravity are well

PUNCTURE FLUIDS

468

MEDICAL ANNUAL

shown in his curves [Plate XXX IX), which bring out the fact that
even a transudate may have as high a specific gravity as an exudate,
although there may be reason for including the fluid, in spite of its
high specific gravit}^ in the list of non-inflammatory cases. The
albumin content varies in a similar way, and the figures afford as
little reliable index to the character of the fluid as those representing
the specfic gravity. The examination for viscosity has been abandoned.
It does not depend upon the amount of albumin present. The range
of variation of freezing-point depression is very Little different in
two classes of fluid. The cellular content of the fluid varies so much
with the stage of the disease that a number of facts require to be taken
into consideration before making deductions.

Marrack^ discusses the cause of milkiness of body fluids without
advancing much further than has been done in the past. He finds
the following possible explanations : that it is lipoid, globulin, or a
lipo-protein. Against the first two are the facts that the turbidity
is not removed by ether, and the granules are not stainable with
Scharlach R. They are cleared by ether after adding potash. These
fluids are alkaline to litmus, and unaltered by centrifuging, shaking with
charcoal, hydrochloric acid, soda, acetic acid, normal saline, or ether.
They are rendered clear by precipitation with an equal volume of
absolute alcohol, or boiling with a few drops of acetic acid and saturat-
ing the filtrate wdth ammonium sulphate. In each case, the clearing
is accompanied by precipitation.

References. — ^Rev, de Mid. 1912, 720 ; ^Quavt. Jour, Med. 1913. July,

463*

PURPURA. [See also Scarlet Fever.)

Herbert French, M.D., F.R.C.P.

Chronic purpura in adults is not common, but it may be very difficult
to cure ; and although it may not kill, it may be associated with
ulcerations and other symptoms \vhich render the patient very ill, or
even bedridden, for years. Some recent cases of this kind are recorded
by Eisner and Header. ^ There are two principal classes : (i) The

continuous form, and (2) The intermittent.

1. In the continuous foim of the disease, patients present symptoms
of general debility and rheumatism, or of gastric or intestinal troubles.
Examination shows ecchymoses or purpuric spots, which have been
present for years, to which no importance has been attached because
of their rapid disappearance. Epistaxis and gingival haemorrhages
are common.

2. The intermittent form appears to be more frequent. In these cases
crises are separated b^’ intervals of vaiydng length. Crises are some-
times preceded for months, or even years, by frequent isolated haemor-
rhages, epistaxes, and stomatorrhagias ; they may be accompanied by
pyrexia. After a variable length of time, often prolonged by the
subintrant attacks so well known in the course of all purpuras, a latent
phase follows w^hen the patient appears cured. Until the appearance
of a new crisis there are no morbid phenomena. More often, if

PLATE XXXIX.

CLINICAL EXAMINATION OF PUNCTURE FLUIDS

Cases

A —Curves of percentages of albumin in transudates (red) and exudates (black).
The continuous linos represent peritoneal fluids, the dotted lines pleural fluids. Ordinates —
number of cases ; abscissa; = percentage of albumin content.

Cases

Fi^^. i9.-— Cunes of specific giavity of transudates (red) and exudates (black). The
continuous lines represent peritoneal fluids, the dotted lines pleural fluids. Oidinatcs--
number of cases ; abscissie — sp. gr, above i,ooo.

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PYELITIS IN CHILDREN

questioned carefully, however, some symptoms are mentioned ; these
include epistaxes, ecchymoses following the slightest traumatism or
prick, or menorrhagia suggesting uterine disease. At other times the
general condition is disturbed ; patients complain of stiffness ; digestion
is slow, painful, and accompanied by heaviness after meals ; patients
accommodate themselves to this condition until, as a result of influences
not well determined, a new crisis follows, confirming the existence of
the chronic and intermittent type of the disease.

Treatment. — It is by no means improbable that purpuras of this
kind are the result of microbial toxins absorbed from some septic focus,
such as the gums or tonsils ; but it is seldom easy to detect the infecting
organism and remove the cause. Any additional means of relieving
the patient’s symptoms is welcome, and Eisner and Header find such
in fresh Rabbit’s Serum, which they inject subcutaneously. From
practical experience they prefer serum from a rabbit to that from other
animals. They advise that it should be given for ten-day periods, with
considerable intervals between successive courses, in order to avoid
as far as possible the discomforts and dangers of anaphylaxis. They
advocate quite small doses — from i to 5 c.c. The beneficial ehects in
the cases they treated were very marked, but the morbid process
was not permanently cured; they believe that successive periods of the
serum treatment are essential.

The cure of a very severe case of Henoch’s pttrpnra by means of
injections of Human Blood Serum is recorded by Wilson.® The
patient, a boy of nine, had received various other forms of treatment,
and his condition was so extremely serious that the prognosis seemed
hopeless, when it was decided to resort to injections of human blood
serum obtained by venesection from the boy’s father. Five injections
were given altogether, on successive days, and all subcutaneously.
The first and second amounted to 45 c.c. each, the third to 72 c.c.,
and the fourth and fifth to 90 c.c.

References. — ^Amer. Jour. Med. Sci. 1913, i, 178; -Med. Rec. 1912, ii,
249.

PYELITIS IN CHILDREN. {See also Urinary Infections.)

Frederick Langmead, M.D., F.R.C,P.

Etiology. — The frequency and importance of infection of the
urinary tract in children by the Bacillus coli communis is becoming
more generally recognized. John Thomson^ has added to his previous
contributions a study of seventy-one cases. He observes that it is
scarcely ever possible to decide in any individual case which route the
bacilli take in passing from their original harmless position to the
urinary passages. It is, however, quite certain that they are some-
times carried there by the blood-stream, sometimes pass in by the
lymphatic channels, and sometimes ascend from outside by the lumen
of the urinary tract. There is great probability that the organisms
often follow a combination of these paths.

Some predisposing influence is necessary for the bacilli to become
pathogenic. Thus, in thirty -tw^o cases out of the seventy-one, the

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symptoms of the urinary disease began during, or shortly after, some
weakening disease or experience. In three-fourths of these the predis-
posing ailment was a bowel disturbance of some kind. Children with
congenital hydronephrosis and dilated ureters, with hypertrophy of the
bladder, are very apt to be infected in the early days or weeks of life.
In fact, if much pus and colon bacilli are found in the urine of a baby
a few days old, and on palpation an enlarged and thickened bladder can
be made out, we are justified in diagnosing congenital hypertrophy of
the bladder, with dilatation of the upper urinary passages-

Symptoms. — He summarizes the more important clinical features.
The disease may begin within the first weeks of life, and is twice as
common in children under two years as it is after that age. Though
generally much more severe in the younger children, it occasionally
presents its severest and most characteristic forms in later childhood.
As a rule, boys are affected at an earlier age than girls. There is a
group of extremely chronic and intractable cases, which is almost
confined to later childhood. These begin after an acute illness —
generally measles ; and many of them prove to be tuberculous.

The relative proportion of cases in the two sexes, and the ways in
which the clinical details differ in boys and girls, are among the most
striking features of the disease. In all the lists of cases published, the
number of girls is much the larger. In Thomson's own cases the girls
formed 79 per cent. The illness in young infants begins more often
with diarrhoea than in older children, and this symptom is more com-
monly severe in boys than in girls. During the first six months of
life, boys are more frequently affected than girls, although after this
period the greatest incidence is among girls. The rarity of rigors at the
onset of the symptoms in boys is noteworthy as compared with girls.
In none of his fifteen male cases did this symptom occur at the onset.
Mild cases of Bacillus coli infection are rare in boys, and in them the
pyelitis is apt to be severe and associated with fatal p^’-elonephritis.
As a possible explanation of these differences in the two sexes, he
suggests that the greater frequency in girls is due to the ease with
which infection may occur per uvethram in them. The frequency of
pyelonephritis in the male sex may be due to the fact that in boys
infection passes straight from the bowel to the kidney and its pelvis.
The much commoner occurrence of rigors in pyelitis in girls than
in boys, or in pyelonephritis in either sex, may mean that the ureters
are that part of the urinary tract irritation of which is most likely
to produce the symptom ; for in the pyelitis of girls the infection is
probably an ascending one.

The symptoms vary with the severity of the disease and the part of
the tract afiected. When it has not spread beyond the bladder, it may
be impossible to recognize any Symptoms, apart from the presence of
pus and bacteria in the urine. Careful questioning, however, may
elicit a history of increased frequency of micturition, with pain or
discomfort during the act, and perhaps also of hsematuria and an
offensive urine.

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PYELITIS IN CHILDREN

The most important cases are those of pyelitis, pyelocystitiSj and
pyelonephritis ; and the striking peculiarity about their symptoms is
the trivial and equivocal nature of the local manifestations, and the
great severity of the general disturbance.

The temperature rises rapidly, reaching 103°-! 05° F., or even higher,
and frequently assuming a remittent type. This may go on for many
weeks, with or without periods of intermission, but under alkaline
treatment the pyrexia generally ends by crisis within forty-eight hours,
although in about half the cases the temperature rises again a few days
after. The frequency of rigors in young children with acute pyelitis
is interesting, because rigors from any cause are so rare at this age.
Vomiting occurs in more than half of the cases, especially during the
first few days of the attack. The extreme misery, restlessness, and
general tenderness from which the children suffer when their tempera-
ture rises, form valuable diagnostic signs. They are drowsy and often
delirious, and if they are very young, frequently squint. The respira-
tory rate often quickens in proportion to that of the pulse. In many
cases there is disinclination for food, even for fluids. Local signs are
either slight or absent. Frequency of micturition is common, and
occurs usually at the onset. In older children, dysuria is more likely
to be troublesome than in infants. Definite vulvitis or vaginitis had
not occurred in any of the cases.

The features of the urine are much the same whether the case is one
of simple cystitis, pyelitis, or pyelonephritis ; but in pyelonephritis
there is rather more albumin present, and a few tube casts may be
found. The urine, when passed, usually looks slightly cloudy or
opalescent, is distinctly acid, and contains many pus cells and bacilli
of the colon group. On standing, it remains cloudy for a long time ,
and a definite deposit is slow to form. The reaction soon changes,
and in time becomes alkaline. On microscopical examination the pus
is rarely seen to be large in amount, and in pyelitis may be absent
altogether when first the temperature rises.

Diagnosis. — ^This depends upon the presence of pus and colon
bacilli in the urine in association with the foregoing symptoms, and
upon the absence of any sign of organic disease outside the urinary
tract which could explain the condition. The exact distribution of the
lesions cannot be accurately determined in young children. Roughly
speaking, patients who have pus and bacilli in an acid urine, with no
fever or distress, have cystitis only ; remittent pyrexia with general
misery signifies pyelitis ; whilst severe collapse with or without pyrexia,
often indicates a grave implication of the kidney.

N. Percy Marsh,- from a study of twenty-three cases, draws a very
similar clinical picture of the disease. He mentions a peculiar and
unpleasant fishy odour of the urine. In three cases, occurring in
infants, general oedema was marked ; and he regards puffiness and
swelling of the eyelids as a not uncommon symptom in older children.
In the latter he recognizes acute and chronic forms. In the acute
form, either the constitutional or local symptoms will predominate,

PYELITIS IN CHILDREN

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depending on whether the case is one of pyelitis or cystitis. In the
former, the onset resembles that of the disease in infants, with shiver-
ings, restlessness, high fever, anorexia, headache, and vomiting.
Herpes may appear on the lips, the abdomen may be slightly distended,
and the spleen enlarged. Nervous symptoms are sometimes severe,
and produce a symptom-complex which may simulate cerebrospinal
meningitis, restlessness and irritability being associated with a crouched -
up attitude, head retraction, muscular twitchings, hypertonus, and
delirium. • When local symptoms are present, the diagnosis is less
difficult, the patients suffering from increased frequency of micturition,
dysuria, and incontinence. Differing from Thomson, he says that
signs of inflammatory irritation are often present around the meatus
and vulva, and that in some cases enlargement of the kidney may be
felt ; in other cases pain may be referred to the subcostal and epi-
gastric regions, and there may be rigidity of the abdominal muscles.
Chronic and persistent infections are occasionally seen in infants, but
more frequently in older children. In these there is a persistent
bacilluria, with but little evidence of inflammation, and little or no
constitutional disturbance. Nocturnal enuresis is not infrequently
met with. The children are generally poorly nourished, anaemic, and
flabby ; they suffer from general malaise, and may have a slight
elevation of temperature which persists over a long period. Periodical
exacerbations are apt to occur, which may assume the form of attacks
like those of cyclical vomiting, or there may be joint pains, with dull-
ness and apathy, resembling rheumatism. In two cases skin eruptions,
consisting of wheals, as in urticaria, and pemphigoid blebs, were the
most prominent manifestations.

Treatment. — Thomson holds that in ordinary acute cases the first
indication is always to ensure a free discharge of urine, usually by
giving large quantities of Fluid to drink. If the patient refuses to
drink enough, the fluid must be administered through a stomach-tube
or by the rectum. The second indication is to see that the bowels
move adequately. For this purpose he recommends Sodium Phosphate,
because it helps in the alkalinization of the urine. An occasional dose
of Calomel is often beneficial.

The urine should be rendered alkaline, and kept so for a week or two
after all pus has disappeared and the signs of uneasiness have ceased.
He favours the use of Potassium Citrate for this purpose. One should
begin with 6o gr. daily if the patient is under two years old ; .but
150 or 180 gr. per diem may be necessary before the urine becomes
alkaline and the temperature falls. Occasionally the urine becomes
alkaline within a day or two after beginning the treatment ; generally
this is attained in four or five da^^'S, rarely in six or seven days, but
never longer in his experience.

Antiseptics, such as Mercury, given by the mouth, may be beneficial
by their bactericidal action in the alimentary canal. Salol, in doses of
2 to 4 gr., three or four times daily, is often helpful, combined with the
alkaline treatment, especially in the later stages. He has found
Uro tropin and its derivatives disappointing.

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PYEUTIS IN CHILDREN

case of Pyelonephritis due to the Bacillus coli conuuun

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Cacioppo, Comba, Dudgeon, and others have found Serum treatment
successful. Thomson has found Yaccines of little use, but has known
them in other hands occasionally quite successful in acute cases,
especially in older children. The large doses of potassium citrate may
cause diarrhoea. ^Vhen this occurs. Still has found that alkalinity may
be maintained by 5 to lo gr. of Bicarbonate of Sodium or Potassium
given every two or three hours. Marsh states that Citrate of Soda
added to infants’ feed is equally valuable. According to this writer, the
treatment recommended by Betz is directly opposed to the alkaline
treatment. He advocates Phosphoric Acid and a meat and no vege-
table diet in order to make the urine strongly acid, limits the amount
of fluid, and prescribes hot-air baths to encourage concentration of
the urine.

Harold W. Wilson® has recorded a case of a girl of 7, in whom the
right kidney was severely damaged as the result of B. coli infection,
the condition resembling that of the usual “ ascending nephritis.”
After an autogenous vaccine had been tried without benefit for sixteen
days, he removed the kidney, and the child made a good recovery.
(See Fig. 45 mid Plate XL.)

References, — ^Lancet^ I9i3» h. 4^7 I -Liverpool Med. and Chir. Jour. 1913,
510; Jour. Child. Dis. 1913, 2S9.

PYLORIC STENOSIS, CONGENITAL.

Frederick Langmead, M.D., F.R.C.P.

Etiology. — Authors are still at variance as to the cause of this
condition, some holding that it is a true congenital malformation,
others that it owes its origin to pyloric spasm, the hypertroph}^ of the
pyloric musculature following the over-action. It is difficult to under-
stand hovT cases could be cured by purely medical means if the former
view is correct. To explain this discrepancy, some of its supporters
contend that an independent condition — one of pure pyloric spasm —
exists, and that it is cases of this nature which get well under medical
treatment. Most English observers, however, do not recognize this
distinction.

Koplik^ classifies cases of the affection into three groups : (i) Pure
spasm of the pylorus and pyloric end of the stomach without the
pylorus being palpable, but with peristalsis, explosive vomiting, loss
of weight, and consequent inanition. Constipation may be absolute,
or little or much faecal matter may be passed, which may be green and
fluid, or brownish. (2) Pyloric spasm with partial or actual stenosis,
with slight or marked thickening or hypertrophy of the tissues of the
pylorus. In such cases there is vomiting of the explosive form, coming
on soon after birth, and continuing for some time, with a palpable
pylorus, either from the onset or developing later. The p3dorus can
be felt to harden under the finger at the time of greatest peristalsis of
the stomach, and to soften after vomiting has occurred. There is
constipation, complete at first, which afterwards lessens. There is
marked progressive atrophy and inanition. (3) So-called congenital
h\’pertroph3^ of the pylorus with stenosis. These cases show exactl}^

tiifi ‘ 'I i-'i ima: / ' vrMc? :■/ /

bacillus COLl INFECTION

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PYLORIC STENOSIS

the same symptoms as those of the previous class, but in a more
aggravated form.

He believes that the condition is due to a neurosis — in some cases
hereditary. In support of his contention, he instances a family group
which came under his observation. Two sisters suffered from the
disease. One of them had two children, and the other one, similarly
affected. The second month of life is the period in which the sym-
ptoms are most severe, and they become less after the third month.
He thinks that the breast milk of some mothers is a direct inciting
element. Peristalsis continues long after vomiting has ceased, and
the pylorus can be felt to harden and soften under the finger long after
the infant is on the road to recovery.

Prognosis. — Koplik recognizes the difficulty of prognosis in these
cases. Some infants with pyloric stenosis and hypertrophy lose weight
slowly after the first decrease, and keep vigorous, though wasted ;
others, with symptoms and conditions apparently similar, lose weight
rapidly, pass into an alarming state of inanition in a short time, and
die.

Treatment. — Whether the treatment should be purely medical or
purely surgical, or whether surgical aid is sometimes called for, are still
vexed questions. Koplik holds that vomiting, peristalsis, and loss of
weight are no indications for surgical interference, however alarming
the symptoms may be. In his opinion, it is only in cases with absolute
constipation and a palpable tumour that the question of surgical
treatment arises, and that even here the vast majority recover by
medical treatment alone. As fully 90 per cent of his apparently
hopeless cases got well without surgery, he regards the prognosis as
more favourable under treatment which is not surgical. He refers
to some of the methods w^hich have been advocated recently. Einhorn
has proposed to pass through the pylorus a bucket, with a dilator
attached to its leading string. As Koplik remarks, any pylorus which
admits of this procedure is not likely to cause the child’s death. Hess
has suggested that a duodenal catheter should be passed through the
pylorus, and either left in the lumen for a time or used as a means of
pouring food directly into the duodenum. Koplik has seen the catheter
fail to pass through the pylorus, and in one mild case, in which it
passed, although the vomiting was temporarily relieved, it returned
with increased intensit3^ He therefore relies on the older methods,
which include very careful Feeding, Lavage, Opium, and, what is of
greatest moment, persistence and attention to detail. He thinks that
in future, more attention should be paid to the relative acidity of the
stomach contents.

The kind of operation which should be performed is still disputed
by surgeons. Fredet,^ who, with Stiles, formerly favoured pyloro-
plasty, now considers gastro-enterostomy the better operation in all
but the less difficult cases. From the point of view of treatment,
he separates the milder grades of stenosis, which are amenable to
medical measures. Such treatment falls under the following heads :

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(1) Reduction of superadded inflammation by diet, lavage, regulation
of nursing, or replacing of milk by a more easily digestible food ;

(2) Control of the spasm by Atropine, etc. ; (3) Maintenance of nutrition
b}^ injections of serum, lavage, etc. It must not be forgotten that
some of the most satisfactory results published were obtained by
Loreta’s operation.

ICeferexces, — Med. Jour. 1913, i. 57; 'Surg. Gyn, ami Obst. 1913,
i> 373 -

RABIES. Herbert French, M.D., F.R.C.P.

Noguchi^ claims to have cultivated the virus of rabies and to have
produced hydrophobia experimentally in dogs, rabbits, and guinea-
pigs, by inoculation with cultures that he has obtained. He believes
that certain granular nucleated corpuscular bodies that he has found

/•Vg. 46, — Cultures of rabies virus, {/l/iist. kbidly hut by La Pressc Mi^dlcale.)

in microscopical preparations from the cultures are actually the living
virus that produces hydrophobia. These bodies have a very pleo-
morphic character, as is shown by the illustration.

Reference, — '^Pvesse MH, 1913, 729.

RAT-BITE FEYER. Hevheri French, M.D,, F.R.C.P.

The bite of a rat is sometimes followed by a peculiar fever, one
remarkable feature of which is that it occurs long after the bite itself
has healed ; the incubation period may be anything from five weeks to
two months. The invasion is generallj^ sudden, with shivering or rigors,
weakness, headache, and p3^rexia ; the healed rat-bite becomes inflamed
and surrounded by tymphangitis. The chart {Fig. 47) shows the pecu-
liar character of the temperature in a case recorded by Rodman.^

The relatively long incubation, and the periodicit}’' of the febrile
attacks, recall some of the characters of relapsing fever, and perhaps

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477

RAT-BITE FEVER

A’/jr. 4S. -Rat-bite fever.— Tnnperature during early fever, twenty-eiqhth to foi tv-fourili
day ( \tigtist 5tli to August 2.;nd)- Character of temperature lasting four aiid a half weeks.

P'ig, 4<5. — Rat-bite fever. — Showing the character of the temperature during the later
period of fever (from .September 15th to October 3rd), and Itusting fur ten and a half weeks.

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rat-bite fever is also due to a haematozoon related to the Spirillmn
ohermeiefi. The charts. Figs, 48, 49, are from an English case recorded
by Cruickshank.’^

A very full account of the disease is given by Atkinson,® with a series
of t>^pical temperature charts.

References. — ^Pvact. 1913, ii. 80 ; Med. Jour. 1912, ii, 1437 ; ^Med.
Ckron. 1913, XXV, i.

RECTAL DISEASES. (See also Anus, Diseases of.)

Sir Charles Bent Ball, Bart., M.Ch., F.R.C.S.

The Surgical Anatomy and Pathology of the Colon, illustrated hy
Radiography . — Granville S. Hanes^ has determined some interesting
facts by .r-ray photographs of the colon distended with bismuth butter-
milk through an appendicostomy wound. No regurgitation of the
mixture took place through the ileo-cfecal opening into the ileum. The
large intestine graduall}’' decreases in size from the caecum to the
rectum ; the hepatic flexure is a gradual curve, while the splenic
flexure appears as a sharp angle at the highest point reached by the
colon in the abdominal cavity.

In order to test for any evidence of anastalsis or reversal of the peri-
staltic wave, the author slowly injected bismuth mixture into the rec-
tum, and with the screen watched it flow’ round to the caecum. He
satisfied himself that the passage of the fluid from the rectum through
ascending, transverse, and descending colon was only the result of the
pressure applied in introducing it, without any sign of reversed peri-
stalsis. He considers the cases in which faeces pass from an ileo-
sigmoidostomy back towards the caecum explained by the fluid following
the line of least resistance, and not as a result of a definite peristalsis.

By radiography, Hanes also investigated the possibility of passing
tubes from the rectum into the descending colon. He found that in one
case a fourteen-inch colonoscope could be introduced, and a skiagraph
showed that the end of the tube had reached a level two inches above
the umbilicus. He then introduced a flexible tube thirty inches in
length, but found by skiagraph that after reaching the commencement
of the sigmoid it had coiled on itself without penetrating further up the
bow’el. By passing a colonoscope to the commencement of the sigmoid,
and a flexible tube through this, it apparently entered further into the
sigmoid but not into the descending colon. After distention of the
large intestine with bismuth mixture and passage of a fourteen-inch
colonoscope up to its w’hole length, the skiagraph clearly show^s that
the point of the instrument had caught in one of the lower loops of the
sigmoid, and pushed this up into the abdomen as far as the mesocolon
would permit ; the greater part of the sigmoid, rendered evident by the
bismuth mixture, was seen lying in its usual position in the pelvis.

Cancer. — K. W. Monsarrat and Idwal J. Williams^ do not appear to
accept Handley’s theory as to the widespread dissemination of cancer
of the rectum, founded on the ground that he had found cancer cells
containing mucin or small masses of mucus, which he supposed repre-
sented degenerate cancer cells, at least six inches above^the cancerous

NEW TREATMENT

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RECTAL CANCER

growth, in the plane of tissue lying between the blind ends of the
Lieberkiihn follicles and the underlying muscularis mucosse, and
which he considered showed permeation of the lymphatic plexus in
this place, Handley's observations were based on the well-known
action of mucicarmine as a selective stain for mucin. The authors
consider it is probably incorrect to look upon the presence of mucin in
bowel carcinoma as a degeneration product, but that it is normally
formed by active bowel epithelium, and its presence in carcinoma
simply shows that the cells have not resigned this form of cell activity.

In four cases of cancer of the rectum which had been removed by
operation, the following method of pathological investigation was
employed. A strip was cut of the entire piece of bowel removed,
passing through the centre of the cancer ; this strip was divided into a
number of blocks of approximately equal length, microscopic sections
of each being made, and the extent and direction of the invasion,
together with the involvement of lymph nodes, marked on diagrams.

Chart I. — Extent of Growth in Various Coats in Case I.

Ulcer measures in,, lower edge about i in. from pectinate line. Invasion
of bowel wall, 3 in. Extension in various coats nearly equal, slightly more
extensive in plane of longitudinal muscular coat. Extension up and down
about equidistant from the edge of the ulcer. Pararectal glands invaded,
higher glands not invaded. No distant permeation in any plane.

. 4 » jr tuc nf s

f\S\f\AAf\/VVV\JV\AAAnf^^

Mucous MCMOttftNt

li 1 ITI rn 111 i 1 1 T |x|xixtx|x|xix| x|v[x|x|y|xlx|x|xlxi ] |.| J | |_}~i | | | |j

tOHStruoiHSt. tmum-c

000

The divisions i to 7 refer to the !)locks
V Growth: (x) = Growth in ftlantl ; () - tTnaffenled

Chart 2. — Snows Infiltration t)F Coats Dkef "lo Ui.cjiR in Case (L

Ulcer measures about i in., lower edge abt)ut in. from pectinate line. All
coats invaded deep to ulcer. Glands not invaded. Extent of invasion of
bowel wall not investigated, but no invasion or ])ernieaiion in strip of wall
from J in. above the ulcer to the jioint of .section of the colon.

iff edteve ffrotuth , no ffrotffth

Mucous nocMonoNs A/VAAA/IAAAAAAAAAA/VVAAAAAAAAA/^J^^'^^SJ^^VU'

Muscutsots utueossi — C ' - t st-

lo^eiruDiffsi Musete^
ffoyeNTtn/f -

X X

0000

X X X X ^

C/freuifi%'”^uscut I U i I M I I I H I I I 1 (It I il I I I I H M I I I I I I I I I Ixlxlxlx lxl i I I I I T IT

Absence of any growtli in length of bowel from point of colon section to w'ithin A in. of nicer.
Absence of growth in glands. X -= tirowth ; O « Unaffected gland ; Not examined.

RECTAL CANCER

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ChaYt 3.— Shows Upward Limits of Extension of Growth in Various
Coats in Case 111 .

Ulcer measures about | in., encroaches on anal canal. Extent of bowel, wall
invasion upwards is about 2i in. above upper edge of ulcer. Greatest extent
of invasion in plane of adventitia, invasion of other coats does not extend
more than in. above edge of ulcer. No distant permeation in any plane.
Glands not invaded.

Mucous J'KArU>JU\f\J\/\AA/\AAAAA^^^

"*" ' ' X X ? ' ' 7 . ~

rm 1 1 1 1 1 1 u 1 1 1 1 1 1 } rt 1 1 1 1 1 1. i:m 1 1 1 ixtxixixi 1 i>i 1 1 1 ixn

MuscuL^sts H)ucosm
Cutcuiam imuseic

LonoiTUOiHSL musette

000

X X X

00000

Absence of growth in glands. The divisions i to 6 refer to the blocks.
>' = Giowth ; O, = Unaffected gland?; = Not examined.

fi/VUS

Chart d* — S how’s Upward and Dow’nw’ard Extension of Growth in all
Coats in Case IV.

Ulcer measures about -J in., extent of invasion of bowel wall about 2-J in.
Greatest extent of invasion upwards in plane of adventitia i in. above upper
edge of ulcer. Invasion uptvards and downwards about equidistant from
ulcer. Pararectal glands affected, high glands not affected. No distant
permeation in any plane.

ic . li ■ I* : IS

... re N tNCHSS

Mueeus AiE/ftoKA/reJ

MuSCVlAjtfS

Sus

■yiMAOAAAAA/lAA/Wj^

Suatffvcostf XX K X xxxxxx

afuacLu TiT i I n 1 1 1 IT ri m ri 1 1 bci^xwxixixixwxtxi I I I 1 1] I i n 1 1 1 m i:n.]

toftsirvojNai. f^ujete^
/fpvMriria .

o o o

<B <9 ^

The divisions t to i6 refer to the blocks.

•= Growth; ~ Growth in gland ; O = Unaffected gland.

These four cases are representative of the commonest type of rectal cancer,
a librous stenosing ad eno- carcinoma, histologically tubular ; the cells have
deeply-stained nuclei, and the cell bodies are almost free from mucin. They
support the vie^v that the disease, in this type, is local for a considerable
period, that it penetrates the wall of the rectum locally, and extends upvrard
and downward, chiefly in the planes of the longitudinal muscular coat and
the adventitia. Further, that this longitudinal extension is not rapid and
wide, but slow and restricted, the greatest distances in the four examples not
exceeding one inch, half an inch, two and a quarter inches, one inch, approxi-
mately. These distances refer to the preserved specimen : in the fresh
specimen they would be slightly greater.

Further, there is no evidence that in this, the common type of the disease,
growth cells and cell groups travel by way of the lymphatic plexuses to any
great distance beyond the local disease ; in particular, that there is no permea-
tion in a plexus associated with the mucous membrane.

This ingenious method of charting the spread of cancer of the rectum
will afford reliable information on an important subject when a larger
number of cases have been similarly dealt wdth.

NEW TREATMENT

481

RECTAL DISEASES

The authors’ general conclusions are as follows : (i) Carcinoma of
the rectum habitually remains localized within narrow limits for a
considerable period ; (2) Permeation of lymphatic plexuses to a

distance beyond the primary site is an exceptional process ; {3) Access
of the disease to the plane between the bases of the follicles and the
muscularis mucosae occurs by invasion from the submucous plane ;
(1) Mucin production in the cells is to be interpreted as indicating
special activity, and not degeneration ; (5) Infiltration is widest in the
plane of the longitiidinal muscular coat and the cellular tissue outside
it ; (6) Glandular invasion is sometimes long delayed ; (7) Without
wide local dissemination, the disease may make its way into blood-
vessels, a process which may be responsible for distant metastasis.

In spite of the consensus of opinion at the German Surgical Congress
in 1906 against the Kraske Combined Rectum Extirpation, the number
of operations by that method, according to Heller, ^ has increased.
From the compiled statistics of the years 1910-1912, Heller reports a
mortality of 29 per cent, over two-thirds of the fatalities occurring in
males. The ideal combined method consists in a primary abdominal
dissection of the tumour and a secondary extirpation from below
through the coccyx route, with implantation of the oral end of the
intestine into ’ the sphincter after the method of Hochenegg. The
principal modification of the operation is the formation of an artificial
anus after abdominal dissection of the tumour and amputation of the
peripheral end of the rectum (Quenu, Hartmann). Heller regards the
combined extirpation of the rectum not as a measure of necessity, but
as one of choice. It is indicated in carcinoma with its upper borders
in the pars pelvina recti, that is, above the muscular diaphragm, because
of its direct relation to the lymphatic glands of the upper haemorrhoidal
vessels. He advises it also in spreading tumours, especiall}?- with
adhesions to the organs of the urogenital tract. The method is contra-
indicated in generalized carcinomatosis, old age, cachexy, arterio-
sclerosis, and adiposity. The advantage of the combined method, and
especially the sacral method, is the possibility, according to the author,
of performing a radical operation because of the accessibility of the
lymphatic glands, the good exposure of the field of operation of the
tumour, the discovery of abdominal metastases, the possibility of
mobilizing the colon while conserving the relationship of the vessels,
and drawing it down to the sphincter. Finally, asepsis can be retained
to the end of the operation. Heller described in detail the method of
conserving the vessels, to avoid gangrene of the oral end of the intestine
following rectal resection. Section of the superior ha2morrhoidal
artery, advised by Rehn, permits the intestine to be pulled down with-
out tension. The ligature is to be placed above the origin of the
arteria sigmoidea (Sudeck’s critical point), in order to retain the colla-
teral circulation. The anatomical landmark is the level of the fifth
lumbar vertebra above the promontorium (Rubesch). In arterio-
sclerosis, or when the mesosigma is short, ligature of the superior
haemorrhoidal artery immediately below the origin of the left colic

RECTAL DISEASES 4S2 MEDICAL ANNUAL

artery does not always, according to Sudeck, prevent gangrene. In
such cases it is advisable not to draw down the intestine to the sphincter,
but to make an abdominal anus.

Primary Melanotic Tumours . — In an exhaustive paper on this subject,
Andre Chalier and Paul Bonnet^ record an interesting instance, and deal
with a large series of cases published by others. The personal observa-
tion was of a man, aged 48 years, with frequent desire to evacuate
the rectum and a sensation that the act was incomplete, and occasional
bleeding. Rectal examination revealed a tumour on the posterior
surface of the ampulla, which felt hard, had a smooth surface, and was
attached by a broad base. It was movable on the deeper structures,
and its upper limit could easily be reached with the finger. This
tumour was removed without difficulty by posterior incision of the
rectum, and the wound was quite healed in ten days. Less than one
month later, recurrent nodules in the rectum were noticed,’ and the
liver was found to be enlarged. Metastatic melanotic growths appeared
in skin, lymphatic glands, and in the abdominal and thoracic viscera,
with great rapidity. The patient died eight weeks after the primary
operation. Autopsy revealed a number of subcutaneous growths.
The peritoneum (parietal and visceral) was covered wdth melanotic
tumours. The liver was enormously enlarged and filled with black
masses ; practically all the abdominal viscera were studded with dark
liodules. The heart and lungs w^ere extensively involved, as also were
the brain, and the spinal column and other bones. Both eyes were
normal. Histological examination of the primary tumour showed
the mucous membrane over it to be normal ; a secondary melanotic
growth close to the anus was found to have originated in a vein.

Primary melanotic grow’ths in the rectum, as compared with the
skin and eyeball, are rare in the human subject, although in some
animals, more especially white and grey horses, they are probably
more common. The authors give abstracts of sixty-four human cases
of this disease collected from medical literature. A review of the facts
related in connection with these cases shows that in many the disease
has originated in the submucosa ; notwithstanding this, the tumour is
stated to be frequently of the epithelial type, although in other cases
it is definitely classed amongst the sarcomata. In the early stages there
is but little pain, and attention is not directed to the rectum until
diarrhoea alternating with constipation, sensation of an obstruction in
the rectum, or haemorrhage, is noticed. In some cases the tumour
becomes pedunculated, and protrudes from the anus after defaecation,
like an ordinary adenoma, giving rise to haemorrhage, and sometimes
proving difficult of reduction. In advanced cases there may be a
discharge of black fluid from the rectum.

In many instances the case was supposed to be the usual columnar-
celled carcinoma, its real nature only being ascertained after removal.
The points of difference are that the melanotic growth is in the early
stage covered by mucous membrane, it is harder than columnar-celled
cancer, it tends to reproduce itself in several isolated nodules rather

NEW TREATMENT

483

REFRACTION, ERRORS QF

than to spread round the circumference of the bowel, it does not for a
long time tend to produce obstruction, and on inspection of it, when
prolapsed or by speculum, the characteristic colour may be seen.

In a few cases patients have lived for many years without recurrence
after the tumours have been removed, while in many the spread of
metastatic growths has been extremely acute. The treatment is
similar to that required for columnar-celled carcinoma.

References. — ‘^Tvans. Amer. ProctoL Soc. I9i3> 86; Jour. Surg.

1913, i, 173 ; ^Surg. Gyn. and Obst. 1913, i, 381 (abstr.) ; ^Rev. ae Chir. 1913,
i. 235 et seq.

RECTAL. FEEDING. Robert Hutchison, M.D., F.R.C.P.

From observations on patients, Mutch and RyffeT are of opinion that
the use of proteins in rectal feeding is valueless. They recommend for
general employment a 6 per cent solution of Glucose in tap-water,
which is isotonic with hlood ; 15 oz. or more may be given to an adult
four times a day, the rectum being thoroughly washed out once daily
with normal saline,

Rendle Short and By waters, 2 who have also investigated the subject
very elaborately, agree that little if any nutriment is absorbed froin a
rectal injection of albumin or peptone. On the other hand, they* find
that some absorption of nitrogen can take place if given in the form of
amino-acids. Amongst their final conclusions are the following :
Modern physiological opinion holds that proteins ate absorbed princi-
pally as amino-acids. The failure of the rectum to absorb ordinary
nutrient enemata is largely due to the fact that peptones are given
instead of amino-acids. Chemically prepared amino-acids, or milk
pancreatized for tw'enty-four hours so that amino-acids are separated,
allows of a much better absorption of nitrogenous foodstuffs from the
rectum, as demonstrated in five cases by the high nitrogen output in
the urine. The low output of ammonia nitrogen shows that this high
output was not due to the absorption of putrefactive bodies. The
rectal washings were not offensive. Dextrose is much better absorbed
than lactose, and relieves the acidosis of starvation. Fat is not well
absorbed. Scarcely any of the fat of ordinary milk enemata is retained.
The best nutrient enema consists of Milk Pancreatized for twenty-four
hours, with 5 per cent pure Dextrose.

References. — ^Brif. Med. Jour. 1913, i, 11 1 ; “Ibid. laGt.

REFRACTION, ERRORS OF. A. Hugh llioinpson, M.D.

Accommodation. — ^The accompanying charts (Vigs. 50, 51, 32), from a
paper by Ernest Clarke,^ show the result of testing the near point (P) of
1600 individuals, with different varieties of refraction, in whom the
error had been corrected prior to the determination of P. The curved
line is Bonders’ average, or mean near point line. The figures above
represent ages, and those to the left dioptres. The results fairly agree
with a similar investigation undertaken by Duane a few years ago.^
From both, the chief lesson to be learnt is the wide difference in the
range of accommodation existing in different individuals of the same

REFRACTION, ERRORS OF 4S4 MEDICAL ANNUAL

age. As be seen from the chart, some children of fifteen have 17D

of accommodation, while others
have only yD. At the age of
forty the power varies from 3*5
D to 8 D. The differences must
be due partly to variations in
the rate at which the crystalline
lens becomes hardened, and
partly to variations in the
power of the ciliary muscle.
This latter factor has been
ignored by some writers but
by those who have much to
do with testing refraction in
children it will not be doubted
that it is the principal factor
in their case. To a healthy
and well-nourished child under
fifteen, a simple hypermetropia
of 2 or 3 D is a matter of prac-
tically no importance ; but with
ill-health and under-nourish-
50.— All cases.— iC. Clarke, ment the reserve power of ac-

commodation decreases, especi-
ally in a state of fatigue, and in default of being able to improve the
conditions of life, the school
oculist frequently finds it neces-
sary to prescribe convex glasses.

In the case of older patients the
differences arc not le.ss marked,
and by Clarke are correlated
with other varying incidents of
increasing age. fn illustration
he takes three men, each lift}^
years old. One may have grey
hair, wrinkled skin, and sclen^sed
arteries. His accommodation
will probably need helping to
the extent of 2-5 1 ) or 3 J).

Another may have none of those
marks of age, and might pass
for thirty-eight. He may prob-
ably be able to read easily with-
out glasses. A third may look
fifty, and need the average
amount of correction for his age
— 1*5 or 2 D. All this tends to
show that the prescribing of glasses for presbyopia is something more
than a merely mechanical routine.

51* — Hypennetrojiic case^. — A', ('/ajkr.

NEW TREATMENT

4S5

RENAL EFFICIENCY

Is Myopia Decreasing ? — ^To this question Risley, judging from
statistics derived from his own private case-books, replies in the affirma-
tive. Already, in 1894, when he wrote the article on school hygiene in
Norris and Oliver’s text-book,'^ he found that this had been the case
in Philadelphia since the more general correction of refractive errors
which had been carried out during the preceding twenty years. In
the present paper ^ he compares the statistics of the years 1894-6 with
those of the years 1910-1912. In the former period, out of a total of
1421 eyes, the percentage of myopia was 14*07. In the latter period,
out of a total of 876 eyes, the percentage of myopia had fallen to 11*21.
The tables show, further, a decrease, not only in the proportion, but in
the severity of the myopia, the
percentage of ‘the higher grades
falling with more or less regu-
larity with the succeeding years,
while the lower grades of less
than 3 D steadily advance, not
in actual numbers but in rela-
tion to the whole number of
myopic eyes. It would be in-
teresting to know whether the
attention which has been paid
to the refraction of London
school children in recent years
has yet been attended by similar
encouraging results. A priori,
one would expect that it would
have, for as was shown by some
statistics of the present ivriter’s
some years ago,® children ivho
suffer from hypermetropic astig-
matism in early school life tend
to become myopic later on,
more than normal children. How far the correction of lefractivc
errors has antagonized this tendency, it is as yet probably loo early to
judge, as far as London is concerned. The subject was discussed at
the T913 meeting of the British Medical Association, and broiiglit out
a considerable divergence of view among those present.'^

References. — ^Med, Press, and Circ. 1913, i, 333 ; '^Med. Ami.,
1910, 524 ; ^Fuchs* Textbook of Ophthalmology, transl. Duane, 4th ed., 820;
’‘ii. 353 ^Jour. Amer. Med. Assoc. 1913, ii, 1169; V^'rit. Med. Jour. igo(>,
ii, 190 ; ’^Ibid. 1913, ii.

RELAPSING FEVER. {See Spirochetosis.)

RENAL EFFICIENCY, ESTIMATION OF. Francis D. Boyd, M.D.

Tests of Renal Activity. — Since Rowntree and Geraghty's original
communication on the estimation of renal function by the injection
of phenosulphonephthalein, a large number of communications liavc
appeared on the subject.

RENAL EFFICIENCY

486

MEDICAL ANNUAL

The method is simple, and can easily be carried out by the practitioner.
The patient drinks 200 to 400 c.c. of water hventy minutes before the
injection. One c.c. of the solution, containing 6 mgrams of the phthalein,
is injected deeply into the muscles of the lumbar region, and the patient
is instructed to empty the bladder at the end of one hour and ten
minutes, and again at the end of two hours and ten minutes. No
account need be taken of the time of appearance of the pigment, main
reliance being placed on the quantity excreted. In cases of urinary
obstruction the catheter must be employed. The urine voided in the
hrst hour is poured into a one-litre measure, water added to 200 c.c.,
and rendered strongly alkaline by the addition of to c.c. decinormal
caustic soda solution, until the maximum red colour is attained. Water
is now added up to the mark, and the mixture shaken and filtered to
remove phosphates. The colorimeter is filled with the red-coloured
clear filtrate, the scale read, and the percentage of excreted pig-
ment obtained. If the urine contains 40 to 60 per cent of the injected
phthalein strongly alkalized and diluted to one metre, the ordinary
pigment of the urine does not disturb the estimation. The first hour
after injection, 43 to 70 per cent — usually about 50 per cent — of the
pigment is excreted ; duiing the first two hours, 70 to 90 per cent.
Excretion is therefore practically complete after tv^o hours.

A diseased kidney shows a very marked decrease in excretion during
the first two hours. At the end of four hours even a diseased kidney
will have excreted most of the pigment. It is, however, sufficient to
watch the patient for one or at most two hours. In cases with only
slight changes in the kidney function, these can be estimated with
efficiency at the end of an hour. In acute nephritis, exci'etion is
noticeably decreased ; in parenchymatous nephritis of some standing,
excretion is always noticeably under the normal. If a diminution
worthy of mention be present, it is claimed that there is always a
definite lesion in the kidney. If only a trace were excreted in four
hours, the prognosis is extremely unfavourable, even if no other sign of
uraemia be present.

When the test is used in conjunction with lu'etei'al catheterization,
the injection is made intravenously, and the urine collected at two
separate fifteen -minute intervals, the time of collection beginning with
the appearance of the drug on the first sight. When the kidneys are
functionating smoothly, and the function is being measured simply
to determine the efficiency of the kidney remaining after a nephrectomy
of its fellow, a collection of fifteen minutes is usuall}?- all that is neces-
sary. If the second kidney is normal, a high excretion of phthalein
will occur sufficient to indicate its efficiency. When, however, both
kidneys are diseased, or when functional estimations are being made
for the purpose of diagnosis, a comparison of the two kidneys being
desired, periods longer than fifteen minutes must be employed. For
short periods the kidneys normally vary very much in the relative
amount of work which each one performs ; but if the time collection
is one hour, the variation will be slight. Phthalein is eliminated

NEW TREATMENT

487

RENAL EFFICIENCY

almost, if not entirely, by the tubules, so the presence of glomerular
disease would not necessarily cause decreased output. The glomeruli
are, however, rarely gravely diseased without considerable resulting
damage to the tubules, and the greater the tubular injury, the more
marked the phthalein decrease. In chronic interstitial nephritis, indi-
viduals with low phthalein excretion are occasionally seen, in whom no
evidence of uraemia is present, and for this reason there is a tendency to
doubt the accuracy of the test. Subsequent autopsy findings, however,
in each case proved the existence of very advanced chronic nephritis.

Lactose is excreted by the kidne5rs, following its intravenous or
subcutaneous- injection. Experimental -work seems to show that
lactose is excreted by the glomeruli and not by the tubules, and it is
thought to determine the condition of the vascular apparatus of the
kidney by the estimation of the excretion of lactose in the urine. Two
grams of lactose are dissolved in 20 c.c. distilled water, and the
solution is carefully sterilized and injected. The urine is collected from
hour to hour. Normally, the excretion of lactose in the urine persists
from four to six hours. Where the glomeruli are involved in the
disease, excretion maj^ be very definitely prolonged.

Normally, the kidney is able to excrete the salt of the food which is
in excess of the requirements of the body. In diseased conditions
there may be salt retention and with it oedema. In diseases of the
kidney, especially where there is tubular involvement, the capacity
for salt excretion may be found defective ; on giving excess of common
salt by the mouth, the salt content of the urine is not augmented, and
increased oedema results.

If 7J gr. of iodide of potassium be administered to a healthy individual,
it will be recognizable in the urine in a very few minutes, and the total
quantity should be excreted within about sixty hours. Potassium
iodide is eliminated by the tubules of the kidney, and where the tubules
are implicated in the disease, the elimination of the iodide is greatly
delayed, in some cases the time being doubled or even trebled.

Thomas gives preference to the indigo cavminc test in estimating
kidney sufficiency or insufficiency, for there is no necessity for ureteral
catheterization wdth its many and obvious disadvantages. Conclusions
should be drawn, not alone from the time of onset of elimination of the
dye, but due consideration must be given to the intensity of the colour
reaction. Although the exact time limit for functionally efficient
kidneys is not yet definitely determined for the excretion of the dye,
as a dark blue it should be placed at twenty minutes, while as a light
blue, fifteen minutes should be the time limit. Any prolongation of
time beyond those limits shows serious interference with functional
activity.

Krotoszyner and Hartmann discuss a lengthened experience of
blood cryoscopy in the estimation of renal function, and find that in the
hands of a critical observer the test is valuable for the estimation of
absolute or total renal function, especially when estimation of relative
function through ureteral catheterization is not feasible.

REWAL EFFICIENCY

488

MEDICAL ANNUAL

Esfhnation of Nitrogen retention is alwa3^s a grave

plienomenon when present in renal disease, and it is claimed that
important prognostic data can be obtained by estimating the incoagul-
able nitrogen of the blood serum. In cases of urcemia, this is present in
higher proportion than in the normal individual. Tn renal disease in
individuals with more than 2 grams of nitrogen per litre of blood, the
prognosis is veiy grave.

By the systematic cmplovunent of these tests, it is thought to differ-
entiate various pathological lesions of the kidney. Delayed lactose
excretion, with a normal iodide and urea excretion, points to a lesion
of the glomeruli, which is usually accompanied by general arteriolar
disease, with hypertension, and exhibits the well-known phenomena
of this type of clinical ]ucture. Dela^’^ed iodide and chloride excretion,
with normal lactose and urea excretion, is found especially when the
tubules arc involved. GEdema, copious albuminuiia, and abundant
tube casts are usually present. Cardiac hypertrophy and h^^pertension
are not prominent phenomena. Uraemia is not a probable ending.
Urea retention is rarely seen in pure form. An acute nephiitis is
frequently of a mixed type, and may proceed to healing, or pass into
a chronic vascular, tubular, or urscmic type.

Kowntree, in the discussion at the American Conference, made
special reference to the prognostic value of studies of renal function.
Functional studies, he points out, reveal only the excretory capacity
of the kidnc}', but do not establish the diagnosis or settle the prognosis.
Still, they should be used as a matter of routine, and the phtlialein and
kictosc test and the estimation of nitrogen retention are of considerable
prognostic importance.

KKincmcxciis.- - Kowntree and Fritz, Arch. Inteniat. Med. 1913, i, 25S ;
kowntree, P'rilz and Geraghty, Ibid. 1913. i, I3i; Barigbt, Med. Rec, 1913,
i, ; Ciuigv. Si)ith 'rrienn. Sess. Amev. Phys. mid Sitrg.\ Aiitcnrieth and
hunk, M finch, wrd. IVoch. 1912, 2657; Pepper and Austin, Amev. Jour.
Med, Sri, 1913, i, 254 ; Geraghl)', Jour. Amev. Med. As.^oc. 1913, i, 191 ;
Goodiuan, fbid. 1913. ii. 1<S4 ; Matthew, Jidhi. Med. Jour, 1913, ii, 153;
Merringhani and 'fn^van, Quart. Jour. Med. 1913, July, 5^3 ; Thomas, Jour,
.imrr. Med, .-Lsaoe, 1913, i, 183; Kroh)SZ3'ncr a.n(l Hartman, 76 /^. 1S8.

RETINA, DISEASES OP. A. Hugh Thompson, M.I).

Ohstnu'iion of ike Central Arievy. — Some years ago, the present writer
published a. sunnnarv of tlic views then current as to the causes of this
(.'(mditirMi.* What was then said still holds good in the main, but the
subject h;is been considerably^ advanced in the interval. Embolism,
at one lime llu; sole recognized cause of the condition, has for many^
years been regarded as only an occasional one. In 1899 Reimar-
doubted wliether it e\'er occurred, because the diagnosis had never been
c(in{irniecl by the pathological examination of a recent case. The oppor-
tunity for such examination must obviously be exceedingly uncommon,
as such eyes do not call for excision ; but a case in point is now to hand
in which a post-mortem was secured four days after the occurrence of
the embolus.'* A clinical observation of Beatson Hird’s* may also be
cited in this connection. The patient was a man with old endocarditis,

PLATE XLI.

RETINAL VASCULAR DISEASE — MICROSCOPICAL APPEARANCES

Fig. A . — The normal central ves-
sels. The artery scarcely has a
separable adventitia, but the iniis-
cularis, though thin, is well develop-
ed. The endothelium seems to rest
on the elastic membrane without the
intervention of any other tissue.
The sectional area of the vein is
somewhat larger than that of the
artery. The vessel is little more
than an endothelium-lined space in
the tissues. There are no muscular
elements in the wall. X reo.

Fig. B . — Endarteritis in the cen-
tral artery. The change is essen-
tially a new formation of tissue on
the inner aspect of the elastic lamina,
which is thrown into folds. The
lumen is much encroadied upon, but
is still lined with a fairly even layer
of endothelial cells. The succeeding
layers are fibrillated. and contain a
fair number of elongated nuclei. The
outer layers are also slightly fibril-
lated, but have a more homogeneous
aspect and are less cellular. There
is no disorganization of the new
tissue. The muscular coat is atro-
phied. The section passes through
the upper part of an organizing
thrombus in the vein, and a little
collateral channel is seen, which w'ill
take part in the re-formation of the
vein lumen, x 120.

^ ,, 'V V'.’#

Fig. C . — Endarteritis in the cen-
tral artery. Stained with Weigert’s
elastic - tissue stain. The elastic
membrane is normal and unthick-
ened. WiUiin it there is a quantity
of new-formed tissue, among which
new elastic fibres are visible.

X 120.

Fii^. D . — A more advanced ex-
ample of the same condition.
Stained with Weigert’s cla.stic-tissue
stain. The elastic membrane is
enormously thickened, and on its
inner asnect there is a new formation
of elastic fibres, some of which are
comparativeU’ coarse, forming more
or less, complete new membranes
within the old. There is some
degeneration of the outer layers of
the new tissue, x 120.

AJ A I >/C. ; L A XyUA L , /p/y

.ninstnxiions kuitilv Jrnt hy Mr. Ot'rrgr Ciuitr

PLATE XLll.

RETINAL VASCULAR D I S E A S E— ^ v/

Fis. F . — A cu'^e in ’vvhidi the cell-
f.hf)\v much degeneration. They
arc swollen, fatty and show a ten-
dency to break down. The tissues
are much better preserved in the
vicinity of the lumen, where also
some elastic fibres survive, x 120.

NEW TREATMENT

489

RETINA, DISEASES OF

and the embolus could be seen ophthalmoscopically as a round whitish
body at the bifurcation of the superior temporal artery. On digital
pressure being applied to the eyeball, the whitish body could be seen to
throb. The history of this case is interesting from the point of view
of treatment. The obscuration of the sight of the eye occurred sud-
denly, and was at first complete. Immediately, the patient rubbed the
eye vigorously, and in about ten minutes the sight partially returned,
though he could see nothing below the horizontal mid-line. Presum-
ably, immediate massage was successful in dislodging the embolus
from a place where it obstructed the main artery to one where it
only obstructed the upper bi'anch.

A far more common cause of obstruction is endarteritis, about which
we shall have more to say presently. A third possible cause is spasm
of the muscular walls of the artery ; but about this there is much
difference of opinion. Some writers have claimed actually to sec with
the ophthalmoscope the alternate contraction and expansion of the
central artery ; but others have supposed that this condition is due to
a stagnant cui'rent of blood in which the corpuscles are agglutinated
into sometimes larger, sometimes smaller, masses. On this theory,
these cases are really due to endarteritis. Instances are recorded how-
ever, which point very strongly to obstruction occurring as the result
of reflex spasm.

As to the other causes formerly assigned in these cases, they may be
ignored. One of them was haemorrhage into the nerve-sheath. This,
doubtless, sometimes happens ; but how it should give rise to the
appearances typical of obstruction it is hard to imagine. Another was
thrombosis, and this doubtless frequently occurs ; but always, one
may say, except in septic cases, secondarily either to an embolus or to
disease of the vessel wall, so that it would be an error to cite it as a
primary cause.

To return to endarteritis, which is now generally acknowledged to be
by far the commonest cause of obstruction. A local swelling of the
intima may reduce the lumen of the artery to such an exceedingly
narrow channel or slit that the resistance offered to the onward passage
of the blood is veiy great. (Consequently, any temporary diminution
of blood-pressure, from whate\x'r cause, may be suflicient to allow the
vessel walls in this particular spot to come into contact, and so stop
the How of blood past it, a state of things which. might either be tran-
sient or permanent. If the former, the condition would very probably
recur — hence the frequency of a history of preceding transient attacks
in cases of complete obstruction. The accompanying figures from an
important paper by Coats^ illustrate the microscopical appeai'ances in
cases of endarteritis of the retinal vessels. [Plates XLI, XLII,
Figs. A to //.)

Detachment oj the Retina.-~~X^.i\, of Cincinnati,'* sent out 4(30 letters
to American oculists, enquiring from each his experience of tlie
treatment of non-traumatic detachment of the retina. He received
281 replies, the cumulative effect of which is somewhat startling;

RETINA, DISEASES OF

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250 out Oi 281 never cured a single case. Many have had promising
temporary results, but in the end failures. Of the remainder,
23 met with a single cure each, 4 met with two cures, and 2 met
with four cures, making in all, 41 cases reported cured. Two of these
cases had detachment due to albuminuria in pregnancy, and they
■were cured after aboition. In about half the remaining cases the
“ cure ” is not convincing from the records submitted. Commenting
on these facts, Vail says, “ In the light of such overwhelming defeat in
oiir attempt to cure this disease, and after having used the knife to
puncture and transfix, the cautery to burn holes, the scissors to cut
windoAvs, the confinement in a dungeon of darkness, with dry diet,
purges, and sweats, the potassium iodide and tight bandage, and after
all and everything has been tried, to have the prospect of cure reduced
to less than one out of 1000 cases, I say the treatment is barbarous,
and even brutal.’* Having said so much, Vail proceeds to propound
a new theory of the causation of detachment of the retina and a new
treatment. The theory is that there is a paralysis of the secretory
functions of the ciliar}?’ processes, which causes a diminution in the
intra-ocular fluid, and a consequent contraction of the vitreous. The
treatment based on this theory aims at the re-establishment of the
secretory function. Acting on this idea, Savage, of Nashville, has
attempted to effect the desired object by alkalinizing ” the intra-
ocular juices. This he does by means of subconjunctival injections of
Sodium Citrate, 15 drops of a 5 per cent solution, repeated at intervals
of a week. The immediate results from this treatment have been very
remarkable, according to Savage ; but as in this disease immediate
results count for comparatively little, it will be well to await further
experience before judging of its value.

References.--“'*0/)/////. Rev. 1902, in Medical Annual, 1903 ; -Arch. f.
Augenheilk. xxxviii, 291 ; '^Klin. jMonatschv. f. Augeiiheilk. xlix, pt. 2, 721.;
'^Ophthalmoscope, 1912, 370; ^Trans. Ophth. Soc. 1913, 30 ; ^*Ann. Ophthalmol.
1913, Jan.

RHEUMATIC FEYER. (See also Rheumatism in Childhood.)

Herbert French, M.D„ F.R.C.P.

Treatment. — Relapses or second and later attacks of acute articular
rheumatism constitute one of the most serious features of the malady,
for in each there is grave danger of cardiac complications, even tliough
the first attack has been recovered from without any such consequences.
It is therefore a matter of great practical moment to discover, if
possible, whether these recurrences are due to entirely separate infec-
tions from without, or whether the patient continues to harbour the
infecting organism after the first attack, so that later ones are not
re-infections, but recrudescences of what has been latent in the interval,
as in malaria. Beattie^ has endeavoured to throw light upon this point
by bacteriological investigations of the synovial membranes of joints,
both of patients who have died after former acute rheumatic disease,
and of rabbits who have recovered after suffering from experimental
acute rheumatism. His results, so far as they go, point to the

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RHEUMATISM

rheumatic diplococci being able to persist quiescent in the synovial
membranes for long periods after an attack of acute rheumatism* He
concludes that recurrent attacks of acute rheumatism are therefore
not separate infections, but true recrudescences or i*elapses of the fii'st.
If so, there is need of devising treatment which will kill off all the
latent germs in the joints and elsewhere. What form this interval-
treatment should take, Beattie is unable to say, but he suggests that if
salicylates will not .suffice, and if atoxyl or other allied effective anti-
protozoal drugs cannot be found, treatment by Vaccines prepared from
the infecting organism of acute rheumatic cases might well be tried.

Considerable controversy has taken place of late over the question
of whether or not Salicylates should be piislxcd to a high dose in cases
of acute rheumatism, as advocated by Lees, who gi\'es up to .^00 gr.
a day in ten separate quantities, rather than less frequently in pro-
portionately bigger amounts at a time. Many objections have
been raised against this procedure ; the more important have been
investigated critically by Miller,- whose analysis concerns 124 cases,
none of which were under his own direct care, but in all of whom
salicylates were pushed more or less. His conclusions are all in favour
of the salicylates. Ho shows that progixssive increase in the dose
leads to corresponding increase in the amount absorbed ; that the
vomiting which salicylates have been accused of producing is primarily
due to excessive cardiac dilatation resulting from the acute rheumatism
itself ; this fact, hov'cver, makes it advisable not to push the dose of
salicylate wiien severe cardiac dilatation is present ; that acid intoxi-
cation is not to be attributed to the salicylates if they are given in the
right Avay ; that the fatalities which have been attributed to salicylates
are not due to the drug but to the rheumatic myocardiopathy ; and
that big doses of salicylates do not predispose to relapses of the rheu-
matic manifestations. He is clearly in favour of giving big doses of
salicylates, together with bicarbonate of soda, in the way advocated by
Lees,

J^EKERKNCKs. — ^lAvcyp, M ed.-C/lir. Jour, 1913, 4S7 ; -Quart. Jour. Med,
19 kh July. 519 -

rheumatism (in Childhood). Fvcdevick Langmead, M,D„ F.R,C.P,

The frequency and extreme importance of rheumatism in early life
is gradually gaining recognition. F. J. Poynton^ compares it with
tuberculosis, pointing out that it may be neither acute nor febrile.
For this reason he prefers the term rheumatism to either acute
rheumatism " or " rheumatic fever."'

Etiology. — He thinks the disease is especially rife when a period
of cold damp weather follows abruptly after one which is dry and
dusty. Heredity is an important factor. The incidence of the disease
increases with each year of life until the tenth to twelfth year, and then
declines. Although rarer in the first few years, he has collected 50
cases of his own at or under five years of age. Females are more often
attacked than males, and of 500 consecutive hospital cases, including

RHEUIVIATISIVI

492

MEDICAL ANNUAL

those of chorea under his care, 319 were females and 181 were males.
He is convinced that cold damp houses are very detrimental to the
rheumatic child, as also are low-lying damp neighbourhoods. As
evidence that direct infection can occur from mother to foetus, he
quotes a case of his own. A child was born at full term, the mother
having suffered from severe rheumatism during pregnancy. On the
second day, the child died ; its mitral valve was found to be actively
diseased, and great numbers of strepto-diplococci were recovered from
the vegetations.

He states with conviction that the avenue of infection is through
the tonsils, for a diplococcus similar in all respects to that isolated by
Paine and himself can be obtained from acute rheumatic angina.
Unhealthy tonsils ai’e very common in rheumatic children. Again, a
sore throat may precede an attack of rheumatism in a most convincing
^vay. In 500 cases this history was obtained in 137, and yet it is
unlilcely that the throat need be actually sore. Disease of the teeth
and gums, in his experience, is not a prominent factor. Poverty is
another predisposing cause, and insanitar^^ houses also favour it. He
regards the arthritis of scarlet fever as true rheumatism ; the post-
scarlatinal cases have the same course in after years as rheumatism
arising independent^.

The writer’s^ investigations as to the incidence of rheumatism
among school children bear out Poynton's contentions as to its preva-
lence, and the path of infection. The percentage of children definitely
rheumatic, out of a total of 2556, w^as 5*2 for children of all ages or
6*83 for children in the senior departments. Out of 133 children
classed as rheumatic, 115 showed some sign of cardiac disorder, An
overgrowth of the tonsils or pharyngeal mucosa occurred in 43*6 per
cent of the rheumatic children, and this was sufficient to warrant
operative interference in 27*8 per cent. On the other hand, the usual
percentage of school-children requiring operation for tonsils and
adenoids is 7 or 8. By a study of 75 cases of chorea, W. P. S. Branson®
comes to much the same conclusion as to the route of infection. Of
these, 21*2 per cent had already been operated upon for the relief of
“ tonsils and adenoids.’' Eighty-three per cent showed evidence of
nasal or pharyngeal inflammation. In 62 per cent the tonsils were
enlarged or had been removed, in 65 per cent the tonsillar glands were
enlarged, and in 50 per cent inflammation of the nasal passages existed.
From these data he infers that the commonest avenue of rheumatic
infection is the tonsil, and next to it the nose.

Clinjcal Manifestations. — Poynton summarizes these as follow’s :
(t) Articular pains, arthritis and teno-synovitis, (2) carditis, {3) chorea,
headache, migraine, (4) pleurisy, (5) subcutaneous nodules and peri-
ostitis, (6) tonsillitis, (7) erythemata, (8) anaemia, (9) hyperpyrexia
(very rare) ; and among other lesions adds nephritis, peritonitis, mucous
colitis, and possibly appendicitis, probably otitis media, meningitis
(very rare), neuritis (interstitial), myelitis ; disseminated sclerosis (?)
mastitis (uncertain), acute pulmonary oedema and bronchopneumonia.

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493

RHEUMATiSiVI

bronchitis (?), phlebitis, venous thrombosis, perivascular fibrositis.
M. R. Bass^ records a case of orchitis associated with erythema nodosum
and acute torticollis.

The disease in childhood, according to Poynton, differs from its less
characteristic form in adults in the following ways : The manifestations
are more varied and more numerous ; the articular lesions, though
frequent, are less severe ; heart affections are more frequent, and
rheumatism for this reason more fatal; multiple cardiac lesions are
commonly met with ; nervous symptoms, notably chorea, are more
frequent, as also are subcutaneous nodules ; sweating is less frequent ;
anaemia is more profound ; there is a greater tendency to drift into
the rheumatic state ; hyperpyrexia is very rare. He speaks of a red-
ness and swelling of the great toe, even in young children, resembling
the gouty toe of the adult, and of the development of ganglia on the
dorsum of the wrist as the result of tenosynovitis.

The most frequent cardiac lesion is dilatation, and the most severe
general carditis. Of the endocardial lesions, initial disease comes first
in point of frequency, and combined mitral and aortic disease next.
Myocardial dama-ge out of proportion to, or even without, valvular or
pericardial affection, demands our close attention. In it the action
of the heart is irregular, the cardiac dullness increased, and the first
sound short. The presence of submiliary nodules in the a-v bundle
may produce a partial or complete heart-block.

Concerning chorea, 122 out of 217 cases showed evidence of obvious
heart disease and other rheumatic manifestations. In 28 more there
Avere arthritis and muscular pain ; in 22 more, cardiac dilatation.
Ten followed sore throat ; 20 of the remainder gave no history of
the cause, but 2 came later for acute rheumatism. Fifteen were
attributed to fright and shock, but in some there appeared to be no
relationship betiveen the tw'O events, and 2 were certainly rheumatic
in later life. Eight were attributed to strain at school, 'fhe onset
may be gradual, and for weeks irritability, inattention, night-terrors,
fidgets, and headache may alone be noticed. Tlie \vi*iter"‘ has pointed
out that long before chorea is recognizable by its erratic mo\'ements,
the child’s school-w'ork deteriorates. It becomes inaccuriitc, slovenly,
and uneven, defects which are best shown in the writing and arithmetic.
The letters and lignres arc badly I'onncd, irregular and wavy, crowded
in some places, spaced in others, and sloping at various angles. When
chorea is not obvious, it may bo suspected by certain ocular phenomena.
The pupils are frequently dilated, and the action of the iris abnormal.
Hippus, inequality increased by accommodation or reaction to light,
and alteration in their shape — the circular orifice becoming oval or
irregular — may occur. One or other may also become excentric.
Poynton states that chorea is often associated wdtli the early stages
of mitral stenosis, particularly when the chorea is persistent or
recurrent.

In his 500 consecutive cases, the Ircquency of the various manifesta-
tions when the patients were first seen -was as follow^s ; 350 complained

RHEUMATISM

494

MEDICAL ANNUAL

of cardiac symptoms, 24S of arthritis and pains, 245 of chorea, 39
showed nodules, 36 rashes, and 137 sore throat.

Prognosis. — Poynton formulates certain prognostic indications.
An acute attack in a veiy young child is always cause for anxiety if
pericarditis develops. Cases wliicli begin acutely with diarrhoea and
a rapid appearance of man^^ manifestations are always dangerous.
Fragile children who have a definite rheumatic inheritance —
particularly if this be derived from both parents — are subject to a
very destructive form of carditis. The supervention of severe chorea
upon a se\'ere carditis is usually fatal. Nodules indicate severe heart
disease. Pericarditis in a case of recurrent rheumatism with severe
cardiac damage is often a terminal event, and develops in practically
all the fatal first attacks. The tendency of rheumatism to recur
introduces a factor which makes prognosis difficult. Speaking of the
outlook in cardiac lesions he gives the following indications : Mitral
incompetence, if slight and well compensated, gives a favourable
outlook, but with a large feeble heart and symptoms of breathlessness
and asystole, a gloomy one. Slight mitral stenosis is compatible with
a long and useful life, but progressive and severe mitral stenosis in
childhood is of grave import for the future. Combined aortic and
mitral disease is very serious when the aortic lesion is well marked ;
when this is slight the case falls into line wdth those of mitral incom-
petence. Primary aortic disease of severity is rare, but the outlook
grave. External pericardial adhesions, which are almost always
associated with a large heart, praecordial bulging, and signs of asystole
on exertion, are ver3’' serious. Many cases of myocardial w^eakness
without valvular disease, though obstinate, eventually do well ; some
of greater severity are most intractable, and may lead to permanent
invalidism. Some cases of pericarditis make excellent recoveries,
but the majority show considerable valvular damage also, and must
be judged accordingl^L The cardiac muscle is very likely to be weak
in such cases. Persistent tachycardia after rheumatism in childhood
is a serious event ; it is likely to be associated with progressive mitral
stenosis. Persistent anaemia is serious also.

Treatment. — As this author points out, preventive treatment holds
out the greatest hopes for the future. He recommends Enucleation
of the Tonsils if they are large, and particularly if obviously diseased.
Although this wall not certainly prevent another attack, it diminishes
the likelihood of it and improves the general health. Branson considers
that the first essential of I'ational treatment of the rheumatic infection
is restoration of the upper air passages to a healthy condition, and
that irrigation and thorough cleansing of the nasal passages, combined
with antiseptic treatment of the nose and pharynx, should be a routine
item of antirheumatic treatment. Few’ wdll disagree with Poynton,
wffio says that rheumatic children need Warm Clothing. He lays no
stress upon diet.

With regard to the treatment of the disease wdien manifestations
are present, he issues a warning against the rash use of large doses of

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495

RHINOPHYMA

Salicylates in delicate rheumatic children, having seen toxic symptoms
attend their administration. He prefers giving 15 to 20 gr. in the ■
twenty-four hours, but has found it in these doses of little value as a
prophylactic measure. He acknowledges the difficulties experienced
in determining the length of time during which Rest should be insisted
upon, but with the appearance of a steady temperature and of the
absence of evidence of active lesions, advises a forward policy.

He regards Yaccine Therapy as still in the stage of investigation, and
emplo^^s small doses, beginning with 1,000,000 organisms and testing
each advance. Sometimes it has seemed to do good, at other times
it has proved disappointing.

In the treatment of chorea the writer emphasizes the importance
of Rest, both to body and mind, and the avoidance of all occasion for
excitement or fear. Little reliance can be placed on the many drugs
which are employed, but Sodium Salicylate has a special sphere of
usefulness, for although its effect on chorea may be slight, it treats the
underlying condition, and may prevent further rheumatic manifesta-
tions. If there is a rise of temperature, salicylate is imperatively
called for, but large doses have not appeared to do more good than
moderate ones. Arsenic is not recommended, for whilst its good
effects are indefinite, its ill effects are sometimes only too clear. To
obtain sleep in maniacal or very restless forms of chorea, Chloral and
Bromides are valuable, especially if combined with Warm Packs. The
treatment by Massage, and re-educative Exercises are of great import-
ance, and by their means i*ecovery may be hastened considerably.

References. — ^Pract, 1913, i, 3S9 ; ^Lancet, 1911, ii, 1133; ^Bvit. Med,
Jam. 1912, hi, 1429; ^Jonr. Amer. Med, Assoc, 1913, i, 1608; ^Brii. Med.
Jour. 1913, i, 1261,

RHEUMATISM, MUSCULAR. {See Fibrositis.)

RHEUMATOID ARTHRITIS. {See Arthritis, Rheumatoid ; Seminal
Vesicles.)

RHINOPHYMA. {See also Nose.) E. Graham Little, M.D., F.R.C.P,

Bordier^ recommends Electrolysis for the hypertrophic masses
which cause the essential disfigurement of this condition. Three
platinum-iridium needles, parallel to each other, arc intx'oduced into
the tumour at a level two millimetres below that of the natural contour
to which it is desired to reduce the nose?." The mmuit;
to the positive pole and the two otliers to the negative. If the patient
is hypersensitive, an injection of iiovocain-suprarenalin may be given.
The amount is increased progreysir^ely until about 40 inilliampdres are
reached ; and the operation may be considered achieved when the
tissues ,assume a grey colour between the needles. The treated aiea
becomes blackened within twenty-four hours, and within fifteen days
separates by diy gangrenous detachment, leaving a remarkably good
cosmetic result.

Reference.' Mid. 1913, 575.

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496

MEDICAL ANNUAL

RHINOPLASTY. Priestley Leech, M,D., F.R.C.S.

Hollander, 1 of Berlin, describes a third method of rhinoplasty.
Where the face is already scarred, he thinks the Indian method of rhino-
plasty is the one to be chosen ; but when the defect in the nose is
isolated, it is better to take the skin flap from some other part than the

forehead. 'He takes the
skin from the chest, as in
the illustrations {Plates
XLIII , XL I V ) . The flap
is protected from the ex-
halations from the mouth
by being wrapped in
moistened gauze and then
in a waterproof material
until the flap is divided ;
after this the lower por-
tion may be turned back
to cover the upper part
of the wound over the
sternum. This is not so
applicable in men with
hairy chests. Rosenstein^
describes another method,
where either skin alone or
skin wdth a thin layer of
bone may be used. The flap is taken from the skin over the chest,
and implanted into an incision under the chin, and when the flap has
taken it is divided and turned up over the nose {Ftg> 53). This seems
a very simple and ingenious method, and obviates the uncomfortable
fixing of the arm in one position.

References. — ^BerL /din. JVock. 1913, 103; Hbid, 1913. 309.

53, — Rhinoplasty, ^vith skin flap from chest (Rosen-
stein method). F'ap is cut from chest and turned up and
fixed under the chin *, later it is severed from neck and
turned up over nose.

RINGWORM. E. Graham Little, M.D., F.R.C.P.

Diagnosis. — Recent additions to our knowledge of this subject
are reviewed by Adamson^ and summed up in the following headings :
(i) The inclusion in_the group of body ringworms of certain eruptions
due to infection by ringworm derived from animals, particularly from
the dog, the 'cat, the horse, and from cattle ; (2) The final pi*oof that
■ rCZGSIu. rrirdTg!n 3 rtnTn^^ really a ringworm, and the discovery

that many so-called eczemas of the hands and feet are also ringworms ;
(3) The demonstration of the animal origin of certain forms of favus ;
and above all (4) The discovery of the new disease sporotriohosis,
formerly mistaken for syphilis or tubercle, but due to a deep invasion
by a mould fungus.

Of the body ringworms, a convenient hut rough clinical classification
is proposed as follows in three groups : (i) Red scaly patches or rings,
generally associated with the ordinary ringworm of the scalp ; (2)

Somewhat more inflammatory ringworms due to infection from the

PLATE XLIIL

RHINOPLASTY— HOLLANDER’S METHOD

A . — Showing po^>ition of skin Hap,

!\IEDI CA L . 1 X XU. I / . /c/ /

— Position of patient on application of the flap.

C . — Patient a ^^eek after, with flap in siii/.
M E Dl C.-l L .-1 AW r.4 L, IQJ 4

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497

RINGWORM

cat; (3) Highly inflammatory ringworms derived from horses and
cattle.

The cat ringworms are probably comparatively common, and they
not infrequently affect the beard as well as the smooth skin. A note-
worthy feature of ringworms of animal origin is that they tend to
spontaneous cure, and that a patient once affected is protected against
a subsequent attack.

Eczema marginakim was proved by Sabouraud to be caused by an
organism which, as it does not infect the hair, cannot properly be
called a trichophyton, which, however, it very closely resembles, and
accordingly the name " epidermophyton inguinale ” was given to the
organism which most frequently infects the groin region in male patients.
It is much less common in females, and when occurring in them is
generally derived from sexual contact with males. Associated with
this form is a weeping eczematoid condition of the fingers and toes,
also due to the fungus, which can be isolated from these parts as well.
Its recognition is of great practical importance, as if mistaken for
eczema, which usually happens, the treatment will probably be futile
to eradicate ringworm, and cases of extreme chronicity may result.
The writer has seen such a case in which the disease had been probably
present in a medical man for fifteen years, and was cured in a few
weeks when its nature was elucidated. All cases of ringworm of the
hands and feet are not, however, to be taken as necessarily due to the
epidermophyton inguinale. One of the most notable of the plantar
infections is with the animal ringworm identified by. Djelaleddin-
Mouktar, which causes a thickening and exfoliation of the skin of the
toes and ball of the foot.

A new variety of favus, achorion violaceiim, has been added to the
four varieties previously recorded. Favus is very rarely contracted
from animals, and then almost exclusively from the mouse, in which
it is not very uncommon. The eruption as it appears on the glabrous
skin may be very like that of ringworm when scutula are not present.
The treatment is the same as for ringworm.

Treatment. — ^The treatment for ringworms of the smooth skin
consists in the destruction of the fungus. This may be effected by
application of Iodine, Chrysarobin, or the following ointment, w^hich is
the most pleasant to use : —

B Acid. Salicyl. | Adipis Benzoat. 5j

Acid. Benzoic. aa gr. xv |

Agnes SavilP experimenting with the lotion of Picric Acid and
Camphor : —

B Acid. Picric. gr. vij ) Spt. Vini Rect. gss

Camphor 3ss j

recommended by Winkelried Williams in the treatment of ringworm
of the scalp, gives the following instructions to be observed in the
application : —

‘ ‘ Directions are given that the hair should be cut round the diseased

RIN6WORIVI ^gS MEDICAL annual

patch in the usual wa}’', and the lotion painted on with an ordinary
camel-hair brush morning and evening. As the lotion evaporates,
a yellow powder accumulates on the head. This powder must be
•washed away lightly at least twice a week, so as to ensure that the
fresh application reaches the scalp. It is important that the hair
should be cut short by clipping or shaving two or three times a week,
otherwise the lotion wdll not penetrate to the scalp, but accumulates
on the hairs. If all these details are carefully observed, the hair
becomes loosened in about tluree or four weeks, and can readily be
pulled out by epilation forceps. Epilation must be performed carefully
with the forceps applied as closely to the root of the hair as possible ;
otherwise the hair is broken off above the scalp, and the disease remains
in the follicle. In order to make sure of the degree of progress of the
disease and of its absence at the end of the treatment, the useful and
rapid method of rubbing over the patches with chloroform may be
used ; as it evaporates, the grey frosted appearance of the diseased hairs
cannot be mistaken or overlooked. When epilation has been performed
roughly, the tiny stumps of the broken shaft are instantly revealed.'*
Garrett^ recommends Liq. Ferri Perchlor. Fort, as a local application
in the treatment of ringw’orm of the scalp. The head must be freed
from grease — by rinsing in motor petrol for example — and w^ashed in
w'ater. The perchloride solution is painted on the scalp with a camel-
hair brush every two days for three applications, then every three
days for six applications. The hair need not be cut, and the child
can attend school during the treatment.

Nock-* has seen good results with an “ old wife’s ” method described
as follow^s. A piece of Sodium Hydrate (household “ w^ashing soda ”)
of the size of a w^alnut is held against a red hot poker until the salt
melts, and the melted end is then rubbed freely into the ringworm.
One such application is said to be sufficient for ringworm of the
smooth skin ; it may be repeated a w^eek later for ringworm of the
scalp. The method is said to be painless and to leave no scar.

References. — Med. Jour. Aug. gth., 1913; ^Pract. 1913, ii, Q-) ;

Med. Jour. 1913, i, 390; ^Ibid. 498.

RUBELLA. E. IT. Goodali, M.D,

According to Gerhard Schwaer,^ the disappearance of the eosino-
philes at the height of the disease is typical of measles only, and not
of rubella ; and a leucopenia during the eruptive stage cannot be
looked upon as the rule in rubella.

Reference. — ^Munch, med. Woch. 1913. 1203.

SALPINGITIS* Victor Bonney, M.S., M.D., B.Sc., F.R.C.S.

Bryden Glendining, Jl/.S., F.R.C.S.

Stone^ treats cases of salpingitis by the conservative method, i.e.,
by injection of solution of Iodine (one part in three of alcohol) through
the dilated cervix uteri and uterine ostia of the tube under pressure.
He has very good results, and mentions one patient wdth gonococcal
salpingitis treated in this w^ay who afterw^ards had two children.
Reference. — '^Jour. Amer. Med, Assoc. 1913, i, 651.

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SCARLET FEVER

S1N0-PLY FEYER. ’ Leonard Rogers, M.D., F,R.C.P.

E. C. Taylor and M, H. Kalan^ discuss the clinical differentiation of
sand-fiy or three-day fever on the Punjab frontier from malaria. The
former begins in J une and lasts to September ; while malaria is preva-
lent during August and September. Sand-fl}" fever is a better term
than three-da}" fever, because in i6i cases the fever only lasted one day
in 45 per cent, two days in 34*4 per cent, and three or four days in but
20*6 per cent. The most constant and characteristic signs are that the
patients come to hospital complaining of pains in the body and limbs
(worst in the loins), catarrh of the conjunctivae and fauces, with redness
of the soft palate, and slow pulse rarely exceeding 100, with a tempera-
ture of 102°, which is never the case in malaria, from which the disease
can be readily distinguished by paying attention to these points. The
blood was examined for malarial parasites in all the cases, with negative
results, except in one case of apparently mixed infection.

C. Birt*^ reviews the literature of sand-fly or phlebotomus fever and
dengue, and notes that the latter occurs as explosive epidemics swiftly
spreading through a community until all the susceptible have been
attacked. It may occur at the same time as the regular seasonal
sand-fly-fever, and one does not produce immunity to the other,
proving them to be distinct. Experiments show that the blood of
sand-fly fever patients is only infective during the first twenty-four
hours, while that of dengue can be transmitted through the blood at a
much later period. Sand-flies fed on fever cases only become infective
after six days, while the Stegomyia mosquito can transmit dengue
directly after feeding on the blood of a dengue patient.

References. — '^Ind. Med. Gaz. 1912, 475 ; ^Jour. Tvop. Med. 1913, 169,
and Trans. Soc. Tvop. Med, 1913.

SCARLET FEVER. E. IT. Goodall, M.D.

Etiology. — Since Griinbaura, in 1904, published the results of
certain attempts he had made to transmit the infection of scarlet fever
to chimpanzees, a number of similar experiments have been carried
out by several observers (Cantacuzene, Bernhardt, Kraus and Land-
steiner, Levaditi, Prasek, and Danulesco) on monkeys and anthropoid
apes. An excellent summary of these observations has been published
by Levaditi.^ It appears to be very difficult, if not impossible, to
infect monkeys, but a certain amount of success has attended the
experiments on anthropoids. The method employed was to smear
the fauces with exudate taken from a case of scarlet fever, and at the
same time, or very shortly after, to inject subcutaneously 10 c.c. of
blood from the patient. After an incubation period of three to six
days the animal has become ill ^vith fever, inflammation of the fauces,
and a reddish, somewhat indefinite exanthem. These symptoms
occurred in five chimpanzees and one orang-outang treated by Land-
steiner and his fellow" workers ; but the rash was not present in three
of the chimpanzees. The tw’o cases with rash were fatal after several
days’ illness. Only in the case of the orang-outang did desquamation

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follow, and microscopical examination of sections of the skin of both
chimpanzee and orang*outang showed appearances just like those seen
in the human subject according to all the authorities. But though
this evidence goes to show that scarlet fever can be experimentally
given to the animals mentioned, the actual cause of the disease remains
undiscovered.

Pathology, — In November, 1911, Dohle,^ of Kiel, first described
certain bodies found in the polymorphonuclear leucocytes in scarlet
fever which, he stated, w^ere of value in the diagnosis of that disease
because they were very seldom found in any other. These bodies,
which are known as " inclusion bodies,’' are round, oval, or curved
bodies, varying in size from a coccus to a large bacillus. They are
distinct from the nucleus of the leucocyte and are usually situated
towards its periphery. Since Dolile described these bodies, several
observers have paid attention to them, and, unfortunately — for it
would be of immense help in the diagnosis of scarlet fever if a patho-
gnomonic sign were discovered — they have not confirmed his statement
as to the limitation of the bodies to scarlet fever. One of the latest
papers on the subject is that by Granger and Pole,^ who, after examining
the blood of a number of cases, not only of scarlet fever but of other
diseases and of normal persons, are forced to conclude that the
presence or absence of the bodies is of no use in making a differential
diagnosis ; ” and further, that the bodies are found in most diseases
caused by ordinary pyogenic organisms, especially if streptococci are
present.” They state, however, that the absence of the bodies
practically excludes scarlet fever.

Symptoms. — J. D. Rolleston,'^ from a study of the blood-pressure in
122 cases of scarlet fever, using C. J. Martin’s modification of Riva-
Rocci's sphygmomanometer, found it subnormal in 25 per cent, the
extent and duration of the depression being as a rule in direct relation
to the severity of the initial attack. In the great majority the highest
readings were found in the first week ; there was also a predominance
of the lowest readings in the same week, but in a large minority the
lowest readings were found in the second week. The normal tension
was usually re-established by the fourth -week. In a majority the
blood-pressure w^as lower in convalescence than in the acute stage.
In 48-4 per cent of the convalescent cases the readings in the recumbent
and erect positions were the same, or the recumbent was higher than
the vertical record until convalescence was firmly established {hypo-
tension of effort). With the exception of nephritis, complications had
little, if any, effect upon the blood -pressure. In only a minority
of the nephritis cases — 12 out of 33 — was the blood-pressure above
normal, and the hypertension was never extreme or of long duration.
Sphygmomanometry in scarlet fever, as in most of the other acute
diseases, is of little practical importance in the acute stage, but in
convalescence may give some indication of the severity of the renal
lesion which may be of value in subsequent treatment of the patient.
Pronounced arterial hypotension, if accompanied by other signs of

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501

acute suprarenal insuf&cieiicy, should be treated by Saprapeual
Extract.

J, Biernacki and A. L. Dykes ^ have published a case of rapidly fatal
purpura following scarlet fever. The patient was a boy, aged six years,
and the purpuric symptoms appeared during convalescence, nearly
eight weeks after the attack. The child died in three days. J. D.
Rolleston,® commenting upon this case, points out that it is probably
one of the class to which Henoch gave the name of " purpura
fulminans.” It difiered from this form in not presenting symptoms
of haemorrhage from the mucous membranes ; but there was no
autopsy. Of 65 cases of purpura fulminans now on record, 18 have
followed an attack of scarlet fever.

References. — ^Pvesse Med. 1912,. 701 ; ^Ceniralbl. /. Bakt. igii, Ixi, 63,
and 1912, Ixv, 57 ; Jour. Child. Dis. 1913, 9 ; 1912, 444 ; ^Bni.

Med. Jour. 1913, ii, 903 ; ^Ihid. 1302.

SCIATICA. Purves Stewart, M.D., F.R.C.P.

Every practitioner knows from his own experience that whilst a
certain proportion of sciatica cases react promptly to simple remedies,
such as rest, local hot applications, etc., yet again there are others
which are particularly resistant. In these obstinate cases, treatment
by Injections, whether into the nerve-trunk itself, or into the perineural
tissues, seems to afford the greatest measure of success. Readers of the
• Medical Annual (1910) are already familiar with Lange’s treatment
of sciatica by large deep injections of normal saline solution containing
0*1 per cent of y 3 -eucaine. Other solutions have been recommended,
such as those containing antipyrin, stovaine, morphine, cocaine, etc.,
but it seems probable that the site of injection is more important than
the composition of the fluid.

Langbein^ selects the lower end of the sacral canal for injections in
sciatica, following the technique of epidural injections originally
suggested some years ago by
Cathelin in cases of frequency of
micturition without evident anato-
mical cause. Lawen^ appears to
have been the first to select this
mode of local anaesthesia for the
treatment of sciatica. It will be
remembered that the spinal theca
terminates at the second sacral
vertebra. Below that level the
nerve-roots in the sacral canal are
enclosed in loose areolar tissue, and
can be reached by epidural injec-
tion. An alkaline 2 per cent solu-
tion of novocain is made by boiling
down the following solution to half its volume : Sodium bicarbonate
0*25 gram, sodium chloride 0*5 gram, novocain i gram, in 100 c.c. of
sterilized distilled water.

54,— Diagram indicating the position of
sacra-coccygeal fontanelle, and the direction of
the needle during the performance of epidural
inj action. —Z, a 7 ighiH.

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The technique of injection is as follows : A lumbar-puncture needle is
used, with a glass s^^ringe containing 20 cx. of the solution. The patient
sits with the trunk strongly bent forward, and with the buttocks project-
ing backwards slightly over the edge of the operating-table {Fig. 54).
The position of the sacro-coccygeal membrane, or fontanelle, which
closes the lower end of the sacral canal, is then identified. Its shape is
that of an inverted U or V. The projection formed by the elementary
laminae or cornua of the fifth sacral vertebra is first felt for. Between
these two cortiua is the membrane, which feels elastic and yields
slightly to firm pressure. In very fat patients it may be impossible to
find the fontanelle. Lawen and Langbein exclude such cases at the
outset. The needle is pushed perpendicularly through the membrane
until it impinges on the anterior bony wall of the sacral canal. The
point of the needle is then slightly withdrawn, and its direction changed
till it runs upwards along the canal, pushing up for a distance of 4 to 5
cm. The fluid is then injected very slowly, about five minutes being
taken to empt}^ the syringe. In a successful case the needle cannot be
felt under the skin, the injection goes easily and without resistance, no
subcutaneous oedema is produced, and the patient usually has a feeling
of tingling or pressure in both legs. - After the injection, the patient
remains with the trunk propped up and the legs dependent. Any
slight feeling of faintness can be checked by a temporary horizontal
posture. In from fifteen to twenty minutes all symptoms of sciatica
disappear. It is advisable to keep the patient in bed for a couple of
days afterwards.

Out of 12 patients (ii men and i woman) thus treated by Langbein,
7 w'ere cured and remained free from recurrences, 4 wxre improved,
and I (a case in which the diagnosis w^as uncertain) was unchanged.

It is not claimed that this treatment should be adopted as a routine
method in all cases of sciatica. A careful diagnosis must first be made ;
arthritis, and intra-pel vie and other local causes must be carefully
excluded, and e\'eii then, Langbein advises that, before resorting to
epidural injections, the patient should have a fortnight’s energetic
treatment with Hot Applications and Antinenpalglc Drugs. The method
is specially suitable to cases of root-pains where the distribution
extends higher up the buttock than in ordinary sciatica. The technique
is admittedly somewhat more difficult than that of injection into the
sciatic nerve trunk.

References, — ^Deut. med. XVoch, 1913. 20 ; ^Deut, Zeit.f. Chir. 1910-1911.

SCLEROTICS, BLUE. Frederick Lcmgmead, M.D., F.R.C.P,

The first mention of this curious hereditaiy anomaly appears to have
been made by Ammon in 1841, but it is only in the last ten years or
so that it has attracted attention. F. A. Conlon^ gives an account of
six members of an interesting family, in which blue sclerotics occurred
for five generations and were associated with osteoporosis. The
colour varies in intensity from a light azure to a very deep blue, and is
present in the whole of the visible sclera. In Conlon’s case it was

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uniform, but in those described by Peters and Bishop-Harman it was
more intense in the ciliary zone.

Most writers on the subject hold that this appearance is due to
abnormally thin sclera, the pigment in the eye being seen through
them, but no histological examination has yet been made. Conlon
points out that if this were the true explanation, the condition
would be associated with buphthalmia and with myopia, but in the
eighty recorded examples which he has collected, neither of those
defects is mentioned. He thinks that the sclera are more translucent,
but of normal thickness, Embryontoxon, an anomaly due to extension
of the upper layers of the sclera into the cornea, has frequently been
seen in association with blue sclerotics, and was found in each of
Conlon ’s cases. The hereditary transmission is direct, and never to
males through unaffected females, and the blueness would appear to
be dominant.”

Osteoporosis was first noticed in these cases by Eddowes, who
described two examples in father and son. In 13 cases collected by
Burrows, 9 had suffered from brittle bones, and of 9 recorded by
Adair-Dighton 5 gave a similar history. In all the families reported
as having blue sclerotics, the tendency to fi'actures from trifling
causes is more or less marked, except in one (that reported by Sidney
Stephenson), and in this one there is no evidence to the contrary.
Radiograms show more particularly thinness of the shafts of all the
long bones as compared with the size of the epiphyses.

Reference. — ^Bost, Med. and Snrg. Jour. 1913. ii, 16.

SEBACEOUS HYPERSECRETION. E. Graham Liiile, M.D., F.R.C.P,

Ruznitzky,’^ in the course of some experiments, claims to have
established the important therapeutic conclusion that Bromides
diminish sebaceous secretion. By taking daily doses of 4 to 5 grams of
bromide, he diminished his own secretion of sebum by nearly one-half.
The method used was to weigh woollen clothes (from which fat had
been pre^'iously extracted) before and after wearing. As, however, the
daily excretion of sebum estimated by various obser^'ers varies from
40*8 gram's (Krukenberg) to from i to 2 grains (Kuznitzky), the methods
of estimation cannot be regarded as above suspicion.

Reference. — '^Arch. /. Derm. it. Syph. 1913, Feb. {Brit. Jour. Derm.
XXV, 240)

SEMINAL VESICLES, DISEASES OF. [See also Prostate.)

J. W. Thomson Walker, M.B., F.R.C.S.

C, S. Lawes and J. W. Sherman' record a case of seminal calculi
simulating nephrolithiasis, and re\'iew the literature of the subject.
These calculi are generally admitted to be very rare. Fuller, in an
experience of 240 vesiculotomies, only met ivith two examples. They
may give rise to spermatic colic occurring at the time of ejaculation.
The pain, IMcHugh states, is felt at the neck of the bladder, radiates
upwards or down to the testicles, is sharp, and may produce nausea.
As a result of obstruction the emission ma}’ be deficient or fail altogether,

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in which case the colic may last for a ievr minutes. The calculi, accord-
ing to Cooper, give rise not infrequently to pain on micturition and
defaecation, which Tuholske describes as referred to the perineum,
groin, lower rectum, and lumbar region. Calculi in the seminal vesicles
may present the clinical picture of renal calculus, w’hich may be ex-
plained by reflex impulses through the abundant nerve supply.

Robert H. Herbst? discusses the surgical treatment of chronic seminal
vesiculitis by Yasostomy (Belfield operation). The following classifica-
tion should be made : (i) Cases of chronic seminal vesiculitis in which
the ejaculating ducts are patent ,* (2) Cases in which they are atresial

or partially occluded ; (3) Cases with complete obstruction of the

ducts ; (4) Cases complicated by stricture of the vas deferens high up.
The cases in the first class are recognized by the ease with which the
vesicles can be emptied by pressure of the finger in the rectum. Most
of these cases respond to stiipping and instillation, and do not require
any operative interference. The cases in the second and third classes
have a partial or complete occlusion of the ducts, and the only hope
for cure lies in some operative measure, such as vasostomy, incision
or excision of the affected organ. The author has abandoned stripping
the vesicles in all cases in which they do not readily empty on pressure
from the rectum. Vasostoni3^ is a valuable measure in the prevention
of recurring attacks of acute epidid^nnitis. Cases in the fourth class
are rare.

The purpose and results of Seminal Yesiculotomy are discussed by
Eugene Fuller. It is a prevalent but erroneous supposition that
incision into the seminal vesicle destro^^s it. The author classifies his
cases of seminal vesiculotomy^ according to the following groups of
predominant symptoms : (i) Urinary^ ; (2) Genital ; (3) Kervous and
mental ; (4) Rheumatic. In the urinary group are most of the acute
virulent cases, in which the gonorrhoeal process quickly^ extends into
the surrounding tissues, “ much post-prostatic general tumefaction
resulting.'’ There is difficult micturition, and often complete retention.
The old w^ay of treating these cases by perineal cy^stotomy was unsatis-
factory. Seminal vesiculotomy gives prompt relief, voluntary and
free urination being usually?' re-established within twenty-four hours.
In the second group the symptoms of sexual impairment predominate,
impotency or marked weakness being the usual feature. The third
group, in which nervous and mental sy^mptoms predominate, is small,
as these individuals are disinclined to submit to operation. The
mental symiptoms complained of comprise confusion of ideas and deficient
concentration, especially’ after sexual disturbances or effort. Mental
depression, even melancholia, is common. ^Marked loss of initiation,
trepidation, and a high degree of timidity’ are not infrequently manifest.
The rheumatic group are all crippled to some extent, and many of them
are bedridden. Tuberculous joints, arthritis deformans, gout, chronic
inflammatory’ rheumatism, progressive muscular atrophy, and myelitis,
are among the diagnoses previously’ made in cases cured by seminal
vesiculotomy^ This operation taps the septic focus, the sy^stemic

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8EPTIC>€MIA

toxaemia ceases, and the crippling lesions resolve. In some instances,
after the toxaemia has disappeared, massage, passive movements, and
other agencies are to be recommended. It is better, however, to wait
for two or three months after the operation before commencing these
manipulations. Fuller has performed the operation of vesiculotomy
in 254 cases without any mortality. ‘‘Of 89 rheumatic patients, there
■was not one who was not radically relieved and satisfied with the
operation result. Eighty per cent of the patients were well and free
from all symptoms when they passed from observation a month or six
weeks after the operation.”

References. — '^S2irg. Gyn. and Obst. 1913, i, 302 ; -Jour. Amer. Med.
Assoc. 1912, ii, 2242 : 'Uhid. 1959 *

SEPTICAEMIA. Herbert French, M.D., F.R.C.P.

Fatal septicaemia due to an organism of the B. proteiis group, gener-
ally regarded as saprophytic rather than pathogenic, is recorded by
Braxton Hicks. ^ The patient, a widow, aged 58, had had an offensive
vaginal discharge for months, and then developed septicaemic symptoms,
suppurating clot being found post mortem in the iliac veins and inferior
vena cava. The same organism was recovered from the blood on two
separate occasions, and its full cultural characteristics are given in
the original paper. It proved pathogenic for guinea-pigs. Although
belonging to the proteus group, it differs in certain respects from
B. proteus vulgaris, and appears to be a species not hitherto described.
It is of some interest in this connection that Bryant long ago recovered
organisms of the proteus group from a series of successive fatal cases
in which ante-mortem thrombosis had occurred in some one or other
of the larger veins.

A very severe case of generalized infection with B. pyooyaneus, ending
fatally, is recorded in detail by Michell Clarke,- in which, besides serious
cerebrospinal symptoms, there was intense jaundice, and the lungs
post mortem were riddled with small abscesses. The B. pyocyaneus
was recovered in pure culture from the blood and fseces during life, and
from the heart’s blood, pleural exudate, and lung abscesses after death.
The author comments on the peculiar cadaveric odour exhaled from
the patient ^vhen alive, and also upon a relative increase of the large
mononuclear cells in the blood, without great leucocytosis ; the latter
may be of diagnostic value in future cases, though blood-culture alone
serves to clinch the diagnosis.

There is increasing evidence to show that Micrococcus teiragenus may
itself cause serious illness in human beings, and that it is not always
merely a saprophytic or associated organism. A case in point is recorded
by Byers and Houston.^ The clinical features were very much those
that may be associated -with galloping consumption, and it was feared
that this was the nature of the illness. No tubercle bacilli could be
discovered in the sputum, however, and eventually the patient got
better under Yaccine treatment. The evidence in favour of Micro-
coccus ietragenus being really the infecting organism responsible for his

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condition, was the presence of this micro-organism in pure culture in
the blood, its presence in the throat, ear discharge, sputum, and urine,
an opsonic index varying with the temperature to this organism (1*7
and 2*i), and the effect of the administration of a vaccine made from
it. The following temperature chart shows the course of the latter
part of the patient’s illness when the vaccines were being given : —

^ Fig. 33.— -Chart of a case of septicaemia under vaccine treatment. — At A, vaccine 2J2 million
given ; at Bj 4 million ;'_at C, iri million ; at D, 2 million ; at million.

References. — '^Lancet 1913, i. 1526 ; Mcd.-Chir. Jour. 1913, 4 ;

^La'ncet 1913, i, 1723.

SEYEN-DAY FEYER. Leonard Rogers, M.D., F.R.C.P.

W. E. Deeks^ describes an outbreak of a short fever in the Panama
Canal zone, which was quite new to observers there. It commenced
among postal sorters of the foreign mails, and spread first in houses
occupied by post-office workers. It was at first thought to be malaria,
but repeated negative blood examinations and the negative effect of
quinine excluded that disease. Deeks describes it as a six-day fever
without a break, while his charts show a terminal rise. It began
suddenly, the pulse generally ranged from 68 to 90, the blood picture
was unchanged, and a trace of albumin was often found. The incuba-
tion period appeared to be about ten days. Pains in the back and
about the eyeballs was noted, but no break -bone pain. A slight
erythematous rash was present in some cases. The spleen was some-
times enlarged. It was distinguished from dengue by being a single-
phase fever. \Mdal tests and blood-cultures were negative. It is
thought by Deeks to be identical with seven-day fever described by
Rogers and Crombie in Indian seaports. The few cases in which Rogers
found B. coli groups of organisms may have been paratyphoids. No
drugs had any effect on the fever, and the mortality was nil.

Reference. — Jour. Amer. Med. Assoc. 1912, ii, 1511.

SINUS THROMBOSIS. (See Otitis Media.)

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SKIN, THERAPEUTICS OF

507

SKIN, EPITHELIOMA OF. {See also Arsenical Cancer.)

E. Graham Little, M,D,, F,R,C.P.

Williams and Ellsworth^ summarize their results in the treatment
of cutaneous epitheliomata with Radium. They regard it as especially
useful in epitheliomata near the eye, and as being preferable even
in early cancers, in which operation is usually recommended. The
number of applications average from three to ten ; if improvement
is not obvious after three, the nature of the growth may be questioned.
If the patient is of low vitality, the success may be delayed. For
keloids of moderate extent, radium is the best means of treatment.

The use of Ethyl Chloride as a freezing agent in the treatment of •
superficial cutaneous epithelioma is recommended by Seidelin,^ who
keeps the tissues frozen for from two to five minutes. There was very
little pain and very slight visible reaction, and no subsequent dressing
beyond the usual aseptic covering is needed-. {See also Skin, General
Therapeutics of.]

Fabry® recommends the combined use of Carbon Dioxide Snow and
X-rays in superficial epitheliomata of the type of rodent ulcer. The
lesion is subjected to two applications for one minute of carbon
dioxide in stick form, with a short interval between the applications
to allow of thawing, and on the same or following day a full pastille
dose of ;r-rays is given to the lesion, to be repeated if necessary.

References. — '^Jour. Amer. Med. Assoc. 1913, i, 1694; Mancet, 1913, i,
1663 ; ^Arch. f. Derm. u. Syph. 1913, Apr. {Brit. Jozir. Derm, xxv 292).

SKIN, GENERAL THERAPEUTICS OP.

E. Graham Little, M.D., F.R.C.P.

The properties of Resorcin are described by McMurtry.^ Upon
exposure to light and air it turns yellowish-brown ; solutions should
therefore be kept in dark well-stoppered bottles. It is very soluble in
water, alcohol, ether, and glycerin ; less soluble in the fixed oils. It
is incompatible with alkalies, menthol, iodine, corrosive sublimate,
permanganate of potash, and the mineral acids. Resorcin may stain
the hair a yellow colour, and the skin brown, effects which can be
removed by citric acid or lemon juice.

In dilutions of -J- to i per cent it arrests bacterial growth ; in dilutions
of 2 per cent and over it is a parasiticide. It is a valuable antipruritic
in aqueous or alcoholic solutions of J to 3 per cent ; in pruritus ani the
author effected a cure wdth the application of a 5 per cent alcoholic solu-
tion repeated hourly until pruritus had ceased, and then continued
thrice daily. In ointments, 5 per cent should be the maximal strength
unless the exfoliative action is desired. In solutions of i to 3 per cent
it exerts a desiccant and keratoplastic effect. It has also a strong
keratolytic effect in ointments of 10 to 50 per cent, and especially in
the form of plasters. It is the basis of Unna's exfoliating treatment
in acue and rosacea. “ A paste consisting of

R Resorcini | Ichthyolis part, j

Pasta Zinci (Unna) aa part, x (

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is rubbed into the face morning and evening, after washing with green
soap and hot water. In three to four days the skin assumes a dry,
stiff, tense appearance, like a mask. At this point the paste is discon-
tinued, and Unna’s zinc varnish (gelatin, alba 30, zinci oxydati 30,
gl^^cerin. 50, aquae 90 ; M. F. gelat.) is applied for twenty-four
hours, after which it is removed with ^varm water, and the homy
layer easily taken off with the fingers or forceps, exposing a rosy
and tender, but well-formed skin beneath. This method gives
highly satisfactory results in seborrhoea of the face, acne vulgaris,
and rosacea.''

A somewhat similar method of exfoliation is described by Darier,
and consists in applying for three successive nights a bandage cover-
ing the entire face in the form of a mask (with the usual orifices) with
the following :

R Tr. Sap. Virid. 20 per cent i Sulphur. Prsecip. part, x

part, xl

Resorcini part, x :

This is allowed to dry on the face, and on the following morning a sooth-
ing lotion or cold cream is applied. There is some pain, but for a few
hours on the first night only. The procedure is repeated each night
until desquamation occurs. Tliis usually begins on the fourth day,
and is complete about four days later."

Resorcin is seldom now used internally, as it has toxic effects which
rasLj be produced even by external use. It should alwa^’S be used with
caution, and avoided for extensive areas. Dermatitis may result in
the less severe intoxications ; in the serious cases, convulsions, delirium,
and even death may occur. Idiosyncrasy to the drug is not rare. A
case of unusual sensitiveness to resorcin is reported by Montgomery.^
The patient, an adult male, developed a very severe reaction ^vith a
paste containing 3-25 per cent of resorcin ; the same effect was noted
with a dilution to half this strength. The sister of this patient did not
show the same idiosyncrasy.

McMurtry^ contributes a very full note on the properties of Salicylic
Acid. Alcohol and ether are the best solvents. It is incompatible
with, amongst others, diachylon plaster, and with silver nitrate. Its
use is contraindicated in the treatment of cutaneous surfaces deprived
of their epidermis and in epitheliomata. Its action is chiefly kerato-
lytic, producing exfoliation, and it appears to have a certain selective
afifinity for pathological tissue. In dilutions of *15 per cent it prevents
the development of bacteria, and is consequently much used in h^^per-
idrosis, to prevent unpleasant smell from sweat ; in dilution of 3 to 4 per
cent it is a powerful parasiticide. Ointments containing 10 to 15 per
cent kill pediculi and nits. The acid has a stimulating effect on epithe-
lial growth when the strength does not exceed 3 per cent. Beyond
this proportion it exerts a solvent action on epidermis, which is found
in its highest degree in the form of piaster, and in its lowest in the
solutions in alcohol and ether. The addition of zinc oxide decreases
the keratolytic effect. Salicylated oils, containing 3 to 5 per cent of

NEW TREATMENT

509

SKIN, THERAPEUTICS OF

the acid, are suitable for hairy surfaces where pastes would be incon-
venient. In using both pastes and oils, the anointed parts should be
covered with oil-silk.

McMurtry^ analyzes the properties of Sulphur as follows. The
precipitated form is so much superior to others that this alone is
considered. Sulphur is only soluble i— 1000 in water, but readily
soluble ill a number of fluids, including ether, alcohol, glycerin, and the
flxed oils. It is soluble in hot aqueous solution of the hydrates of
potassium, odium, barium, calcium, forming polysulphides and
thiosulphates. It is incompatible with a very large number of sub-
stances, including all metallic salts and metals ; with nitric, picric,
chromic, and h^j-drochloric acids ; with hydrogen peroxide.

Extemall}^ the action is keratoplastic and vasoconstrictor in dilu-,
tions of 4 to 10 per cent, an action which is increased by addition of
alkalies and soap. A moderate keratolytic action may also be pro-
duced by sulphur as in the exfoliating paste recommended by Lassar,
which consists of

B.' j 3 -Naphthol part x I Vaselini

Sulph. Prascip. part. 1 | Sapon. Nigr. aa part, xxv

This is applied to the face and removed at the end of thirty minutes
with a wet cloth. A dermatitis results after several applications, and
the horny layer peels off as with a strong resorcin paste.

As a parasiticide sulphur acts probably by reason of the generation
of sulphuretted hydrogen. It is still the most valuable agent in the
treatment of scabies (xo per cent ointments). When used in this form
of ointment, dermatitis not infrequently results, and sulphur in the
form of powder may be preferred. The powder is rubbed into the
skin and the undersheet copiously dusted wdth it. Cure usually follows
in nine to ten days. As this method requires no baths, and does not
involve greasing of the clothes, it oflers advantages besides that of
avoiding dermatitis. Sulphur also protects against bed parasites —
fleas, bugs, and lice, — and may be used in the form of the following
powder dusted over the body or on the sheet : —

R Sulph. Prsecip. | Talci Pulv. gr. xx

Camphor. Pulv. aa gr. xl [

Ft. pulv.

Powdered sulphur may also be used in 5 per cent strength for
hyperidrosis. In the form of lotion sulphur is very useful, though
less active than in ointments. A convenient form, especially in
facial acne, is : —

R Zinc. Sulph. I Gb^erin part, x

Pot. Sulph. aa part, xij j Aq. dest. ad part, cc

To be well shaken before use.

Or this : —

R Sulph. Praecip. ] Aq. dest. part, cl

Gb’cerini aa part, x | Amyli q.s. ut. fiat emuls.

SKIN, THERAPEUTICS OF

510

MEDICAL ANNUAL

In pityriasis simplex of the scalp, G. T. Jackson’s sulphur cream is
highly recommended : —

E. Cerai Alb. 3 ihss Sod. Bibor.

01. Petrol. §iiss Sulph. Praecip.

Aq. Rosai gj

To be rubbed into the scalp twice a week.

gr. XV
3 iiiss

For acne rosacea, and seborrhoic dermatitis, 15 to 25 per cent
strengths may be used. The following is a formula of the author’s : —

Resorcini

Sulph.

Camph.

aa part, x

Acid. Salicyl.

Lanolini

Vasilini

part. V
aa ad part, c

Apply night and morning, with massage, after washing the
face with soft soap and hot water.

For pigmented areas, chloasma, etc., the following paste is
suggested : —

R Sulph. Praecip. part, xx I Acid. Acetic, q.s. ut. ft. pasta

I mollis.

Sulphur soaps are largely inert unless the lather is rubbed into the skin
and left on from ten to twenty-four hours.

Sulphur should never be used in acute inflammations, or on surfaces
denuded of epithelium, or in persons -with eczematous tendency. When
applied over large areas toxic symptoms may result ; and there is often
an idiosyncrasy to the drug \vhich must be kept in mind.

The action of sulphur is also discussed by Foerster,® who reviews
the literature fully. Two view^s have been held as to the manner in
which sulphur acts. One propounded by Unna ascribes its activity to
the production of sulphuretted hydrogen in contact with the skin ; the
other by Brissoii, who regards the formation of sulphuric acid as the
explanation. Foerster supports Unna’s view, and remarks on the
clinical experience of various sulphur preparations ; the most active
of these, Vleminckx’s solution or liquor calcis sulphurata, made by
boiling lime and sulphur together, probably ow-es its efficacy to the
production of hydrogen sulphide and nascent finely-divided sulphur,
which is deposited oh the skin.

Under the heading of dry treatment of moist dermatoses ^ C. J.
White describes a method of dressing with Berated Talc which he
personally recommends, especially in extensively exudative disease.
The patient is kept in bed throughout, an air mattress being a useful
adjuvant. Diet consists of soft solids,” with abundance of water ;
no baths are allowed. Borated talc powder is applied with a sifter
very freely, the patient lying naked in bed, the coverings being sup-
ported by a frame. The floor and walls of the room are bare, and all
superfluous furniture is removed. As there is much dust when the treat-
ment is efficiently carried out, the aural, nasal, and mouth orifices may
be protected. The limbs should be separated so that no portion of
skin rubs one upon the other. If there is much suppuration, a prelimi-
nary treatment with Black Wash is recommended, and this must be

NEW TREATMENT 511 THERAPEUTICS OF

repeated if collections of pus occur. Combined with the local measures
which are regarded as the most important, large doses of Quinine were
used in some of the cases with apparent benefit. The diseases in which
the “ dry ” method was tried were chiefly exfoliative dermatitis and
pemphigus, and the results compared very favourably with another
series of cases treated by miscellaneous methods.

Ichthyol. — ^^IcjMurtry" points out that the chemical’ constitution of
ichthyol is not exactly known, but it is probably a sulphoichthyolate
of ammonium. Its content of sulphur, on which its therapeutic value
is largely dependent, would appear to be variable. Ichthyol is entirely
soluble in water, and in equal parts of alcohol and ether. It mixes
freely vrith glycerin, oils, and fats. It is incompatible with, among
other substances, acids, alkalies, alkaloids, mercuric chloride, and
resorcin. Its most valuable therapeutic effects in external use are
those of an antiseptic, antiphlogistic, antipruritic, and vasoconstrictor ;
used internally, it acts as an intestinal antiseptic and astringent, and
is much used in cutaneous hyperaemia. It may be given with equal
parts of peppermint water in doses of 3 to 5 drops three times daily
on an empty stomach, and the amount taken may be increased to
60 drops a clay.

It is one of the best local remedies in erysipelas, and may be used
pure, or in ointments containing 20 to 30 per cent. Combined with
iodine (i to 3 per cent dissolved in alcohol and ether ; not the
tincture, the potass, iodide of which is incompatible with ichthyol) it
has a greatly increased antiseptic effect. In frostbite and htirns it is
especially indicated, in the form of ointments or lotions, from 10 to 50
per cent in strength. For burns of the first degree, a powder may be
recommended : —

Zinc. Oxidi

part. XX j Ichthyol.

part, iij

Magnesii Carb.

part. X 1

Or this paste for burns of the second degree : —

Calcii Carbonat.

part. X Zinc. Oleat.

part. X

Zinc. Oxidi

part. V Ichthyol.

part, iij

Amyli

part. X Aq. Calc.

part. X

In rosacea and acue vulgaris, ichthyol is used in ointments or lotions
of 2 to 50 per cent strength, or it maybe applied pure to the skin in very
indurated cases. Its internal use in these affections is also widely
recommended. Boils, carbuncles, and kerioii do well, painted with
pure ichtlwol. In ichthyosis, baths of i per cent ichthyol, iii "which
the patient is immersed for twenty minutes, promote exfoliation of
the horny masses and softening of the skin.

Vaccines. — ^Whitfield, in common with other observers, finds this
treatment especially valuable in furunculosis, and prefers to give as
an initial dose 250 millions of the autogenous staphylococcus, raising
this by rapid increments. The injections should be continued so as
to ensure freedom from boils for at least three months. In pustular
folliculitis, chronic pyogenic eczema, and ordinary impetigo contagiosa,

SKIN, THERAPEUTICS OF

512

MEDICAL ANNUAL

when contaminated as it always is in later stages by staphylococcus,
\'accines of these organisms are very useful. In early sycosis it is
sometimes beneficial, but frequently fails in cases of older standing,
and in these, depilation by ;t'-rays hastens the effect of the vaccine.
In erysipelas, small doses of an autogenous vaccine of streptococcus
(five million) , followed by a second and perhaps a third of the same
quantity at five-day intervals, frequently results in complete cure.
In acne, the mixed acne and staphylococcus vaccine should be used
in combination with local remedies, and constitutional treatment for
dyspepsia, constipation, etc. Vaccines have no influence on the
underlying factor of seborrhoea. In hipus vulgaris, treatment by Old
Tuberculin is recommended, if there is no evidence of visceral tubercle.
The dose which gives no reaction is doubled until reaction occurs.

The author prefers other means of treating lupus, but vaccine therapy
may be useful in combination with local methods. Tuberculin is
especially useful in Bazin's disease, but must be administered here
with greater caution. In varicose ulcers, vaccines have been disappoint-
ing, In pruritus ani, vaccines of B, coli and streptococcus have been
tried with poor success. In ringworm of the lidiicy scalp, vaccine therapy
is of no practical use.

Gilchrist^ described some interesting experiments and results of
employing a filtrate of living organism in blastomycosis. He also
found some success in employing ointments made up with dead
organisms in cutaneous infections, but these investigations are in too
earh’ a stage to yield practical suggestions for treatment. Vaccines
from intestinal cultures were tried with some promise in certain
diseases, e.g., urticaria and erythema muliiforme, in which intestinal
toxins are wont to play a causal part.

Human Serum. — May*er and Linser experimented A\ith injections of
human serum in certain skm diseases, especially those occurring with
pregnancy and in urticaria. Praetorius^^ reports a most remarkable
cure obtained in an extremely severe and chronic case of pemphigus
hy a single intravenous injection of 20 c.c. of undefibrinated fresh
human blood. This author regards the addition of living blood-cells
as a most important advantage as compared with serum alone.
Ravaut^^ recommends the following modification of the method
advocated by Spielhof and Prsetorius. Twenty c.c. of the patient's
own blood are withdrawn from a vein and injected intramuscularly
into the buttock ; the dose may be repeated on the fourth and seventh
days, and oftener if required. Pruritus was very markedly influenced
by this method in eczema and dermatitis herpetiformis. Stumpke^-
has experimented with serum injections in a number of cases. In
psoriasis and seborrhoeic eczema no advantage w^as noticed from the
injections ; but in a pruriginous eczema there w'as considerable relief
of the itching ; in prurigo of Hehra, several injections of fresh
undefibrinated human blood produced no effect, and this author, in
contrast with Prsetorius, found no reUef of a severe pemphigus from
these injections. In lichen planus, serum injections produced in one

NEW TREATMENT

513

SKIN, THERAPEUTICS OF

case a cure within fourteen days ; in another case great inipio\'ement
resulted, but for other reasons the treatment could not be continued.
In a case of herpes gestation is in a woman pregnant nine months, three
injections of normal serum produced considerable improvement, but a
complete cure resulted from two further injections of serum from a
pregnant woman. In urticaria, blood transfusion was successful in
removing wheals and relieving itching.

Haslund,^^ as a result of a large experience in the use of Carbon Di-
oxide Snow, recommends it as the method of election in treating lupus
erythematosus (exposures being on the average 12 seconds), in rosacea
(exposures of 6 to 10 seconds), in cavernous angiomata (15 to 20 seconds’!,
and in warts (maximum of 60 seconds). For port- wine stains and for
rodent ulcers he prefers light or radium treatment.

Morton reviews his later experiences with freezing by this
reagent. He regards it as easily the best treatment for ncem,
other than " port- wine stains,” in which the effect is sometimes brilliant
but uncertain. For hairy moles it is frequentlj^ disappointing, and
electrolysis is probably to be preferred. For warts it is still the best
method. For rodent ulcer it is not as overwhelmingly superior as this
writer thought with earlier trials ; but it remains, notwithstanding, a
most valuable method. In the treatment of chronic circumscribed
patches of eczema it is very useful. In trachoma it is preferable to
other treatments.

[The writer uses carbon dioxide freezing extensively and with much
satisfaction, both in the solid form and dissolved in ether. The latter
method has been singularly successful in the treatment of ulcerating
lupus of the nasal orifice and septum nasi, in varicose and chronic
septic ulcers. He has found the stick method very useful in dissipating
gummata, in treating soft corns, and in several cases of dry lupus
vulgaris. For small rodent ulcers the writer still regards it as the best
method at our disposal. — E. G. L.]

Bowen remarks on the frequency with which ignorant use of X-rays
results in disaster, and would restrict their legitimate use to : (i)
Surgically inoperable epitheliomaia ; (2) Epitheiiomata in cases in

which the patient refuses surgical intervention ; (3) Small cutaneous
epitheiiomata, in which the cosmetic result is very important ; (4)
Sycosis and' obstinate local pruritus ; (5) A few other cases, e.g.,

obstinate patches of psoriasis and eczema, mycosis fitngoides, and
a few rare affections of the kind.

Sibley^ recommends Electrolysis in the destruction oi sebaceous cysts
in preference to their removal by the knife. An aluminium needle
attached to the negative pole is inserted into the cyst, and a current
of 5 miiliamph'es continued for one or two minutes. If the cyst be
large, another method is recommended : some drops of normal saline
are injected into it, and two copper needles, one negative and one
positive, parallel but not touching, are introduced, and a current of
2 to 5 milliampA-es turned on for three to five minutes. The copper
deposited round the positive needle mav prevent its ready removal,

SKIN, THERAPEUTICS OF

5x4

MEDICAL AN NU Al-

in, which case the current is reversed with the needle in situ. Both
needles are then withdrawn and the wound is closed with collodion.
The contents of the cyst are often expelled spontaneously through
the opening, or may be squeezed out of it some four to seven days
after the electrolysis. The procedure may be rendered painless by
preliminary infiltration with 2 per cent solution of novocain.

Some useful general principles are enunciated for X-ray administra-
tion : (i) Any dose between f and i pastille should not be repeated
within three weeks. This dose is suitable for ringivonn, favus, keloid]
hyperidrosis, angiomata, warts, ncevi, rodent and epitdieliomatous growths
generally. (2) A |-pastille dose be repeated at the end of two
weeks, and again in three weeks, for vernicose lupus, ulcerative tuber-
ciilosis, and tuberculous glands. (3) A -pastille dose may be repeated
at the end of a week, and again after two weeks, and then after three
weeks’ interval, for chronic eczema, psoriasis, lichen planus, pruritus
ani, acne, and sycosis. (4) A -l-pastille dose may be repeated weekly.
This is suitable for some forms of alopecia.

Simpson X" reports a series of cases of different nature treated by
Radium applications, which he extols in epithelioma, angioma, lupus
vulgaris and lupus erythematosus, tuberculosis verrucosa cutis,
persistent syphilides, blastomycosis, sycosis vulgaris, keloid, hyper-
trichosis, neurodermatitis, dysidrosis, ringworm of nails, lichen planus,
psoriasis.

Mesothorium, — KuznitzkyX® recommends this agent in a number of
diseases, compi'ising carcinomata and rodent tdcers, warts, hmnangiomata,
ncevi, and lupus erythematosus. The treatment is carried out by
applying mesothorium in a capsule fixed over the part with strapping,
and left in position for twenty minutes to an hour. The actmty of the
reagent is due to beta and gamma rays. As compared with radium
the rays are softer and the superficial reaction more evident ; it appears
within a day or two of application as a light erythematous patch, which
darkens to a brownish-red at the end of a week, when serous exudation
begins and superficial necrosis of the epithelium' takes place. In the
fifth week, the crust which is at first formed generally falls off,
and the scar left by this treatment is comparable with that obtained
by carbon-dioxide freezing. The price of mesothorium (£7 los.
per milligram) makes the treatment of limited application; in the
author’s experiments, capsules containing 20 mgrams were used. {See
also Thorium, p. 60.)

The use of Adhesive Plaster as a direct dressing for wounds and
■ulcers_ is recommended by Hutchins,^- who thus describes the method :
the skin is cleaned with benzine, and strips of adhesive plaster (one-
inch width is recommended) applied either directl3’, when there is not
much exudation, or with the interposition of cotton -wool when dis-
charge is copious, in such a manner as to make an air-tight dressing,
which must be renewed dail^’-. The plaster need not be sterilized ; no
special make is recommended, but the author prefers zinc oxide
adhesive plaster.

NEW TREATMENT

515

SKIN, TUBERCULOSIS OF

Salvarsan or NeosalYarsan powder, diluted with xeroform in 1-3
proportion, and dusted on the surface of chronic ulcers (one applica-
tion followed by dry dressing with xeroform), is recommended by
Alston.

Organotherapy. — ]Morris-^ usefully summarizes the evidence for
associating certain disorders of the internal secretions with dermatoses.
Thus he reasons that because Thyroid Extract is curative of rnyxoedema,
it should be useful in skin diseases not myxcedematous, but having
certain S3niiptoms in common with that disease, e.g., dryness and
absence of perspiration, loss of hair. He has found it advantageous
in psoriasis, especially in adipose patients ; in ichthyosis, alopecia,
and xerodermia, pruritus and eczema, sclerodermia, keloid, warts,
acne vulgaris, rhinophyma and rosacea, lupus and scrofulodermia,
affections of the hair, including defluvium and premature greyness,
degenerative change of the nails, and in abnormal pigmentations.
The dose should be small, beginning with 2J gr. in adults, and J gr.
in infants, and should be controlled by symptoms, of which nausea,
rapid pulse, headache, and lumbar pain are the most important.

The pituitary body has close relations with the thyroid — in acromegaly
and in goitre both glands are usually simultaneously affected. Hyper-
pituitarism is associated with hypertrichosis and hypersecretion of the
sebaceous glands. Overgrowth of the long bones is ascribed to func-
tional hyperactivity of the pituitary body, and may be accompanied
by distention of the skin (striae cutis distensae).

The thymus gland probably has some vicarial relation with the sexual
glands, and disorders of the thymus may be associated with acne
vulgaris. Morris has used with advantage Thymus Extract in acne,
Pituitary and Suprarenal Extract in persistent urticaria and angio-
neurotic oedema, and Suprarenal in lupus erythematosus.

References. — '^Jour. Cutan. Dis. 1913, 255; -Jour. Amer. Med. Assoc.
1913, i, 2035 ; ^Jour. Cutan. Dis. 1913, 166 : '^Ibid. 322 ; 1912,

665; ^Ibid. 705; '^Ihid. 1913, 64S ; ^Pvoc. xviith Iiiternat. Congr, {Med.
Sect,) xiii, pt. i ; ^Ibid, ; ^^Mimcli. med. Woch. 1913, 867 ; ^^Ann. de
Denn. et. de Syph, 1913, May {Brit. Jour. Derm, xxv, 375) ; ^-Deut. med.
Woch. 1913. 1447; ^^Arch. f. Derm. u. Syph. cxviii {Brit. Jour. Denn. xxv,
374); ^^Lancet., 1912, i, 1730; ^^Boston Med. and Surg. Jour. 1913* 682;
-^Pract. 1913, i, 611 ; Anier. Med. Assoc. 1913, i, 80 ; '^^Arch. f. Derm,

It. Syph. cxvi, 1913, Apr. {Brit. Jour. Derm, xxv, 293) ; ^^Joitr. Cutan.
Dis. 1913, 470 ; -^Brit. Med. Jour, 1912, ii, 174S ; "'^Ibid. 1913, i, 1037.

SKIN, TUBERCULOSIS OF. E. Graham Utile, M.D., F.R.C.P.

Ehrlich’s discovery of a drug which has a special affinity for the
organism causing syphilis has stimulated other experimenters in the
search for a similar agent in tubercle. Briick and Gluck, ^ apparently
influenced by Koch’s discovery, in i8go, of the peculiarly effective
bactericidal po%ver on the tubercle bacillus in vitro of solution of cyanide
of gold, have experimented with very dilute solutions of Potassium and
Gold Cyanide, first in rabbits, to determine possible doses, and then in
human beings, and have evolved a system of treatment for which they
claim a remarkable success. In a series of cases in which no otlier

SKIN, TUBERCULOSIS OF

516

MEDICAL ANNUAL

treatment was adopted, they were satisfied that the therapeutic effect
obtained justified the conclusion that this drug has a specific effect on
the tubercle bacillus. The drug is given dissolved in 50 c.c. of water,
for adults in doses of *02 to *05 gram every two or three days ; for
children (from six to fourteen years old) in doses varying from *005
to *03 gram. The solution is freshly distilled, and freshly sterilized
water is given intravenously, following exactly the same precautions as
in injecting salvarsan. Local reactions rather like those follomng
tuberculin injections may sometimes occur, but no serious constitu-
tional effects were noticed in a large series of injections. A course of
twelve injections is usually recommended, but this number may be
exceeded. The authors later combined with the gold and potassium
cyanide injections treatment by Tuberculin, and came to the decision
that the combination worked more quickly and better than either
method alone. The tuberculin was usually given twenty-four hours
before the injection of the drug, and the dose was regulated by the
usual consideration, being pushed to a point just short of the produc-
tion of pyrexia,

Bettmann^ confirms generally the conclusions of Bruck and Gluck.
He used somewhat smaller doses, beginning with *01 gram in 50 c.c.
of water, and gradually raised the dose to *03 gram. The injections
were given with intervals of at least two days. There were no serious
symptoms noted in 250 injections. Some local infiltration and hemor-
rhage occurred in one case, but this was not important. The method
was tested with sixteen cases of lupus vulgaris ; of these, thirteen had
fourteen or fifteen injections, averaging about *4 gram in thirty-two
to forty rthree days. The tuberculin used was varied ,* it was chiefl}^ old
tuberculin, in doses commencing at -ooooi ,gram and gradually raised.
By this method, rise of temperature was but seldom noted, and local
reaction vras quite moderate. Reuter^ also used the combined method,
and with satisfactory result, in fifteen cases of lupus vulgaris
or lupus erythematosus. In only two cases was there any untoward
effect, one of these being a patient with severe constitutional illness
and disseminated lupus erythematosus, in whom the rise of temperature
to 103*5° F* ii^ay have been partly due to the general illness ; the other
was in a patient with lupus vulgaris of the cheek, who ten days after a
second injection of *03 gram developed a brawny infiltration of the arm,
with loss of power and local haemorrhages. Reuter gives injections of
gold and potassium cyanide twice a week, commencing with *02 gram
and increased to *05 gram. Injections of old tuberculin i

mgram) were given from twenty-four to forty-eight hours before
the intravenous infusions of the gold salt. Twelve such injections
forined a course. Reuter agrees with Bettman in regarding the
effect of these injections as cumulative ; but he is less optimistic
than the previous writers as to the future of this method in general
practice.

RefereihCES. — ^Miinch. med. Wuch. I 9 i 3 > 57 i -Ibid. 709; '^Deut. m:d.
iroi;/?. 1913, 1727.

NEW TREATMENT

517

SKJN-aRAFTINQ

SKIN-GRAFTING. (See also Breast, Cancer of.)

Priestley Leech, M.D., F.R.C.S.

Sabella^ and Stern,® of New York, have published papers on the use
of the fceial membranes instead of skin for covering skin defects. If
this method should justify the claims made for it, it will be of great use.
Sabella uses the amnion and umbilical cord ; these are examined, and
enquiries are made as to the previous history of the patient, etc. If
their appearance is healthy, they are placed in a bottle containing
normal saline solution, after having been washed in warm water to
remove any vaginal secretion, etc. When the patient is ready for
grafting, the foetal tissues are dipped several times in a new solution of
normal saline, and then cut up into pieces in any shape and size desired.
The cord is cut open, and the blood-vessels are scraped out ; the surface
of the cord and amnion which is to be placed on the ulcer should be the
continuation of the inner surface of the cord. The area to be grafted
should be carefull}^ cleaned and disinfected ; exuberant granulations
should be levelled down, and any undermined edges of the skin must
be cut away until health}’ skin is reached ; then the surface is thoroughly
asepticized. All bleeding must have ceased ; if oozing persists, the
surface must be covered by a protective layer of rubber tissue, of silver
foil, guttapercha tissue, or oiled silk, over which sterile gauze is applied,
and the grafting put off till next day, w^hen it may be finished if the
bleeding has ceased. When the whole surface has been grafted,
fenestrated oil-silk is placed over it, then sterile gauze soaked in deci-
normal salt solution or Carrel’s solution, and over that a layer of rubber
tissue, so that the moisture may not evaporate. Over this, more sterile
gauze is placed, and then an ordinaiy^ dressing. The first layer of
gauze is changed everj^ day and replaced by gauze soaked in salt
solution. In order that the grafts may not be moved by the daily
dressing, the fenestrated oil-silk is fixed at its edges with collodion.
Before grafting, Sabella cleans the area thoroughly with peroxide of
hydrogen, which is washed oft with a 1-10,000 mercury perchloride
solution.

Stern uses a rather different method ; the freshly obtained amniotic
sac is washed clean in normal saline solution, dried between layers of
sterile gauze, and immediately immersed in petrolatum which has been
raised to the melting-point over a water-bath. The receptacles are
stored on or near ice as soon as possible. The denuded surface is
thoroughly cleansed of all secretion and bits of tissue, and (if infected)
well washed with iodine or strong permanganate solutions ; it is then
treated with a perchloride dressing. Grafts are now taken from the
petrolatum, spread smoothly on the surface, and a wax, composed
of paraffin, bees’-wax, and castor oil, is melted, and spread over the
graft with a little cotton wound on a wooden applicator to retain the
graft in place, and then an outer dressing of cotton and a bandage.
After two days the dressing is removed. The wax w’as suggested by
Carrel.®

Wiener^ has tried skin-grafting without the use of any dressing, and

SKIN-GRAFTING

5x8

MEDICAL ANNUAL

reports very good results. If there are any sinuses, these are plugged
with iodoform gauze, but the grafts are left uncovered. Ten days
after grafting, a weak ichthyol ointment is applied.

Staige Da\ds^ reports a case of excessive formation of epithelium in
grafts dressed with amidoazotoluol ointment; the patient has been
under observation for two years, and there are no signs of malignant
degeneration.

References. — ^Med. Rec. 1913, i, 478; ^Joitr, Amer. Med. Assoc. 1913.
X 973 i ^Ihid. 1912, ii, 523 ; ^Ibid. I 9 i 3 > i, 1526 ; ^ Johns Hop. Hosp. Bull.
1913^ 178.

SLEEPING SICKNESS. [See Trypanosomiasis.)

SMALL-POX. E. W. Goodall, M.D.

A curious and rare case of what appears to be a recrudescence of
the eruption has been recorded by Fink.x The patient was a male
native of Burma, aged 22, He 'went through a moderate attack of
small-pox, which began on i8th, 1912, contracted upon admission
to gaol. On August 7th he was quite well and put to ordinary labour.
He increased in weight and looked perfectly healthy. “ On Sept.
26th, 1912, he had an attack of fever, but the temperature was not
recorded. The following morning papules appeared, and some of them
developed into vesicles. A few of these vesicles became pustular, and
scabs formed. The lesions were in every respect similar to those of a
mild case of chicken-pox or modified small-pox. The prisoner had
not been in contact with any person suffering from either of these
diseases. The eruptions were most numerous on the back and chest,
and there were a few on the face and extremities. They were all very
superficial, and the scabs were thin. On examining the hands, two
'' seeds “ [evidently remaining from the attack of small-pox in IMay]
were found on the palmar aspect of the left hand, and one ... on the
right middle finger."’ The glands in the axillary and femoral regions
were enlarged to the size of a pigeon’s egg. By October 4th all the
scabs had fallen off.

Reference. — '^Jonr, Trop. Med. and Hyg. 1912, 353.

SNAKE-BITE. Leonard Rogers, M.D., F.E^C.P

A brief resume of a report by W. B. Bannermani on an investigation
into the treatment of snake-bite by Permanganate of Potash has been
published, in which a table of the results obtained in dogs with both
cobra and Russell’s viper venom is given. As pointed out b}" L.
Rogers," these experiments show from ^o to S3 per cent of recoveries
of the animals which had received from one to three lethal doses of the
venoms. Yet the author sums up his results as proving the method
to be of no use whatever as a practical measure for employment after
actual snake-bite. Rogers, after criticizing this conclusion as not
being in accordance with the experiments recorded, gives a table of
twenty-one cases of snake bites in which the snakes, including cobras,
kraits, daboias, and other vipers, were identified by reliable observers!

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5^9

SPINAL CORD

no less than twenty of which recovered under the local application of
crystals of permanganate of potash by Lauder Brunton's method.
Ko substitute for the treatment is suggested by Bannerman, so that
the permanganate method remains the only practical measure in the
vast number of instances, owing to the extreme unlikelihood of suffi-
cient active antivenene being available when required.

F. W. Fitzsimons® has published a pamphlet on snake-bite and its
scientific treatment. As a result of prolonged experiments he has
found that various alleged antidotes in use in South Africa are useless.
He advocates permanganate of potash rubbed into incisions made at
the site of the bite within five or six minutes of the bite as the only
first-aid remedy, and the subsequent injection of Antivenene. He has
patented an outfit containing both the first-aid apparatus to be carried
in the waistcoat pocket, and antivenene syringes, and an illustrated
booklet to enable the full treatment to be carried out.

References. — ^Ind. Med. Gas. 1912, 381 ; Mbid. 467 ; Snake Bite and
its Scientific Treatment.”

SPINAL CORD, SURGERY OF. E. W, Hey Groves, M.S., F.R.C.S.

Newton^ has carried out some most instructive experimental work
on the subject of concussion and compression of the cord. He has
worked with 50 animals, mostly cats, with a few monkeys and dogs.

A glass rod weighing 50 grams was allowed either to fall upon the
cord from a measured height, or else to compress the cord for a given
time. The following practical conclusions are drawn from these
experiments : (i) The spinal cord is extremely sensitive to slight degrees
of concussion and compression ; (2) Despite the slight anatomical
changes demonstrable after lesser degrees of injury, the resulting dis-
turbance of function is considerable ; (3) After concussion which has
quite abolished motor efferent conduction, sensory conduction can still
be demonstrated ; (4) Arrest of the spinal-cord circulation by aortic
compression abolishes spinal-cord function in from fifteen to thirty
seconds ; (5) These experiments support the view that there is an
organic basis for the signs and s\nnptoms of “ railway spine” and
allied conditions of traumatic neurasthenia.

Spinal Tumours . — Symptoms. — As in the case of the brain, so wdth
the spinal cord, one of the most pressing problems is the relation of
surgery to the treatment of tumours. It was only in 1887 that a
tumour of the cord was first rightly diagnosed and removed, and until
recently such cases were regarded as rare curiosities. Now, however,
that it is possible to collect over 600 records of spinal tumours, this
view must be altered. And the point of greatest practical importance
w^hich is impressed on the mind by these facts is, that whereas spinal-
cord tumours are in reality fairly common, they are often overlooked,
and come to be classed among those hopeless cases of paraplegia or
multiple sclerosis which languish without hope or treatment.

Potel and Veaudeau^ have collected an immense amount of infor-
mation on this subject. Tumours of the spine may be classified as

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520

MEDICAL ANNUAL

(i) Extra-vertebral; (2) Vertebral; (3) Intra vertebral — [a) Extra-
medullar}’, (b) Intramedullar}’.

The exiraveriebral tumours are those which arise in adjacent organs
and thence spread to the interior of the spine, either by erosion of the
bones, or much more commonly by fungating through the intervertebral
foramina. In 72 per cent of cases the tumour is a sarcoma, in 16
carcinoma, and in 10 hydatid cyst. The origin of these growths may
be from the muscles of the neck and back, or from the mediastinum
and abdomen.

The invasion of the spinal cord and nerve roots is signalized
by symptoms very similar to those attending tumours of the vertebral
column itself. Wherever the posterior face of the spine is the seat of
the growth, it should be attacked, directly there is evidence of cord
involvement, because although the growth may be malignant and
liable to recur, a free removal of laminae will relieve the cord from both
pressure and destruction. WTien the tumour grows into the spine
from in front, nothing can be done.

Vertebral tumours constitute about two-thirds of all spinal growths,
and of their number over 80 per cent are malignant growths secondary
to breast cancer. The primary disease which gives rise to them is of
a very chi’onic character. The symptoms have a general resemblance
to those of Pott’s disease. Bone deformity, however, when present,
is not angular as in tuberculosis ; it takes the form of a long gentle
curve because a number of adjacent vertebrae are softened simul-
taneously. In addition to this, and the presence of a primary growth,
these cases are distinguished from Pott’s disease by the absence of pain
on pressure, and by the fact that rest in bed causes no improvement
in the pain. The root pains are the most prominent symptom. They
are very severe, bilateral in distribution, and of long duration. The
evidences of cord pressure come on long after those of root irritation,
and consist in the usual sequence of spastic paralysis with exaggerated
reflexes, flaccid paralysis with absent reflexes, and paralysis of sphincters.
The course of these cases is usuall}^ about one year. There is no kind
of radical treatment available for such conditions, but various attempts
have been made to relieve the intolerable root pains. This has mostly
taken the foim of resection of ^’aTious posterior roots, but it has met
with but little success, owing to the necessity of exposing the roots at
the site of the grow’th and the rapid extension of the disease after
operative interference. Lately, the proposal has been made to divide
the paths of pain-conduction in the antero-lateral column of the cord
on the side opposite to that of the pain, or on both sides. This has
the advantage of being feasible at some distance above the growih,
and of not requiring more than a small exposure of the cord. {See
Medical Annual, 1913, p. 454.)

There are records of about 22 cases in which operation has been
done for the relief of pressure on the cord. Of these, 13 have been
benefited, and there are a few cases, comprising primary hydatid
disease, exostoses, enchondroma, and sarcoma, wiiich have been cured.

NEW TREATMENT

521

SPINAL CORD

It is - exivamediillavy sub-group of intravertebral tumours {Figs.
56, 57) that is of the greatest surgical interest, because, in sharp con-
trast to cerebral tumours, the great majority are either benign or of a
very low malignancy, and early operation is attended by slight risk and
a good prospect of permanent cure. The growth is in most cases a well-
defined oval fibro-sarcoma or purely fibroid tumour (80 per cent), and
the remainder are made up of endotheliomata, angiomata, hydatids,
and carcinomata. The cervical region is affected in 20 per cent, dorsal
in 52 per cent, lumbo-sacral in 18 per cent. In gross character, the
tumour in 95 per cent of cases is solitarjr, easily isolated, and it is
situated outside or inside the dura mater in about equal proportions.

The symptoms caused by these growths may be divided into three
stages, although these are often not sharply marked from one another.

Fig. 56. — Extramedullary aucl extradiual
tumour lying outside and in front of the
dura.

Fig. 57. — The tumour after removal
of dura. Note the relation to two nerve
roois on one side, which have been cut.

1. There is pressure upon the nerve roots. This causes pain of a
ver\’ intense character, which the patient locates in a definite spot in
the periphery. ^Mien the growth is in the dorsal region, for instance,
the pain shoots along one of the intercostal nerves, or is most intense
in the li3^pochondrium. Having begun on one side or at one spot, it
tends to spread further, but the seat of origin remains as that of the
maximum intensity, hlarkedly unilateral pain is specially charac-
teristic of intradural growths. This stage lasts for a year or more
before symptoms of cord pressure arise, and it may terminate by a
condition of flaccid paral^^sis with atrophy of muscles, due to a compres-
sion of the motor elements of the nerve roots.

2. Then appear the phenomena of the unilateral cord-pressure, i.e.,
a modified Brown-Sequard paralysis, movement being diminished on
the side of the lesion, and sensation on that opposite to it in the parts
belo^v the tumour. The presence of this special phase of extra-
medullary tumours will evidently only be present when the growth

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522

MEDICAL ANNUAL

is unilateral, but when ' it is absent the absence has no special
significance.

3. There is compression of the cord. The first evidence of this
(apart from the above-mentioned second stage) is spasticity, with
motor weakness, accompanied by an increase of reflexes and the
development of painful involuntary contractions. This is gradually
succeeded by flaccid paratysis, with paralysis of the sphincters.
Sensation is lost to a less degree, and long after motion.

The intramedullary tumours {Figs. 58, 59, and Plate XLV) are for-
tunately much rarer than the last class. They affect the dorsal region
most commonly (50 per cent), next the cervical (33 per cent), and all
other regions together (17 per cent). They are always gliomata or
sarcomata of some type. In rather more than half the cases the

^Vg. 55. — Intramedullary growth (after
Elsberg). The tumour is just seen through
a longitudinal inc\sion in the cord.

tumour is encapsuled and therefore removable. They are always soli-
tary, without any tendency to spread to other parts or to cause
secondary growths. Their presence in the cord is revealed, after
opening the dura, by an absence of pulsation, some modification
of feeling or appearance, or by a fusiform swelling. The S37mptoms
are much less definite in their character and sequence than in -the
case of extramedullary tumours. Pain is usually absent, because
there is no direct pressure upon the roots. Motor paralysis of a
limited distribution occurs, and pari passu with it is atroph}’,
accompanied by fibrillary contractions. This atrophy and paralysis
ascend gradually as the tumour grows in length. The sensory
symptoms are vague and indefinite, the most characteristic being the
dissociation of sensation such as occurs in syringomyelia, there being
a loss of pain and temperature sense without tactile anaesthesia. The
intramedullary tumour grows in the axis of the cord, and therefore, as

S succ«

Fig. A . — Very large tumour of
the conus and cauda equina, re-
moved successfullv at operation.

.)/FPJC.-^L AXyUAL, 1014

NEW TREATMENT

523

SPINAL CORD

the case progresses, there is merely an extension in the area of atrophic
paralysis, rather than an increase in the evidence of compression such
as occurs in the extramedullar}?- tumours.

Diagnosis. — ^IMany points have already been mentioned, and the
matter ma}?- be summarized under the following headings : —

1. Diagnosis of an intravertebral -tumour has to be made from
disseminated sclerosis, certain forms of lateral sclerosis, and spinal
serous meningitis. As regards the latter, the distinction is perhaps
not of great practical importance, because in either case a laminectomy
will be required.

2. The diagnosis of extradural from intradural growth is also not of
great importance, as it will.be cleared up by operation. Well-marked
symmetry of root pains points to an ex-tradural, unilateral signs to an
intradural growth.

3. Diagnosis of the level of the tumour is as difficult as it is
important. There are many cases in which an operation has failed
to find a tumour which has been revealed on the post-mortem
table. The chief difficulty arises from a confusion between the level
of segmentary compression and that of the loss of conduction. For
example, when an intramedullary growth is in the dorsal region,* there
may be no root pains, and muscular paralysis with atrophy is difficult
to detect in the intercostal regions. Altered sensation and motor
weakness in the legs may misdirect attention to the lumbar region of
the cord. The general mistake is therefore to seek for the tumour
too low, and it is a good rule to be guided by the highest level of altered
sensation. Further, when nothing is found, but the cord is not
pulsating, it is wise to open up the laminas above, until the tumour
is reached, or at any rate a part of the cord which shows normal pulsa-
tion. There have also been a few cases in which the tumour was
sought too high, this being due to an cedema above the growth causing
segmentary symptoms above it. The most important factors in
settling the level of the grovdh are : (a) The earliest pains of onset,
which, being generally root pains, correspond to a segment of the cord
situated some distance higher than these roots (the cervical segments
are i vertebra higher up than the roots connected with them, the
upper dorsal 2, and the lower dorsal 3, whilst the last dorsal to the fifth
sacral roots inclusive are all opposite the last dorsal and the ist lumbar
vertebrae) ; (b) The site of muscle atrophy ; (c) The hyperaesthetic zone
above an area of anaesthesia, or in the absence of this, the upper level
of anaesthesia or dissociated sensation, (As every part is supplied
wdth sensation by at least three consecutive sensory roots, the level of
the tumour will be at least three segments above the level indicated
by the upper margin of altered sensation.)

Treatment. — In all cases of intravertebral tumours of the cord this
consists in Removal, when possible, after a free laminectomy. There
are, however, a few points which require discussion : —

I. The simple removal of lamince as compared with the use of an osteo-
plastic flap. There is really nothing to recommend the latter — it is

SPINAL CORD

524

MEDICAL ANNUM.

merely a dissecting-room demonstration. There is no evidence that
the strength or rigidity of the spine suffers from the removal of even
five or six laminae. Further, it has been sho^ that the bones in
an osteoplastic flap undergo atrophy, and there is great danger of
the ill-nourished flap sloughing. A simple laminectomy is easy, safe,
and rapid, and it can readily be enlarged in either direction

2. The posture of the patient Probably the lateral position is the
best, because the fully prone position causes weight on the chest and
embarrassment of respiration. An elevation of the pelvis is of advantage
in saving excessive loss of cerebro-spinal fluid, but this latter point is
one to which surgeons seem to attach but little importance, with an
increase of experience.

3. The ancBstheiic, Krause has employed local ansesthesia, novocain
I per cent Awth adrenalin solution 1-50,000. Probably when surgeons
become familiar with the advantages of the intratracheal ether method,
this will be always used in these cases, as it ensures complete aeration
of the blood wdth the minimum of shock or respiratory embarrassment.

4. Exploration, When the tumour is not at once discovered, aid
may be sought by use of a sound or catheter, passed first between the
dura and bones and then between the dura and pia. If the cord, by its
absence of pulsation, firmness, or bulging, gives indication of an intra-
medullary growth, it should be incised in a longitudinal direction to one
side of the longitudinal fissure (to avoid the posterior spinal arteries),
and the growth will then extrude itself either at once or after the lapse
of some days (see Figs. 58, 59). In the latter event it is to be removed
at a subsequent operation.

The mortality of the operations from spinal cord tumours has dropped
from 45 per cent to 15 per cent, and it w'ould no doubt be much lower
if cases came earlier for operation. It is to Elsberg^ that we owe most
of our knowledge of the possibility of the removal of intraspinal tumours
by spontaneous extrusion. The figures on Plate XL V are from his cases,
and illustrate well the size and shape of both extra- and intramedullary
growths.

Surgery of Nerve Roots. — Foerster^ has given a recent summary of
the results of the operations of the resection of the posterior nerve
roots, together with his latest views upon the subject.

The operation has been done for pain 38 times, and of these onty 12
were successful. Those in which the relief of pain has been immediate
and absolute, in the way in which we should have expected, w’ere cases
where only a single root w^as affected. The most disappointing cases
have been those of limb neuralgia, whether this has been of spontaneous
or traumatic origin. From this it is clear that in such there is so wide
a diffusion of pain sensation among adjacent nerves, that it will be
impossible to abolish it without very extensi^’e root division. Foerster
actually declares that to abolish pain in the arm, we must divide from
the third cervical to the third dorsal (i.e., nine consecutive roots), and
for that in the leg, from the tenth dorsal to the fifth sacral (i.e., twelve
consecutive roots). Such an extensive nerve resection could only be

NEW TREATMENT

SPINAL CORD

525

justified if the pain was in the stump of an amputated limb, because
of the extreme ataxia that would be produced bv it.

For visceral crises the operation has been done 64 times, and of these
6 died at once and 4 others shortly after. There were 56 successful
cases, some of them having relief maintained for several vears, but most
having been too recent to judge of the final operati\^e results. In cases
where failure has occurred, the division of the roots has not been
extensive or radical enough. In Foerster’s first case, only the seventh
to the tenth dorsal roots were cut, but now he says that it is better
to include from the sixth to the twelfth, because there is some
variation in the course of the sympathetic nerves from the stomach to
the cord. As evidence that the roots have been thoroughly divided,
there should remain a permanent zone of absolute anaesthesia from the
mammary level to that of the navel.

For spastic contractions there have been 159 operations, with 14
deaths. It can now be clearty predicted which cases are likely to give
good and which bad results. Those unsuited for root resection are
cases of disseminated sclerosis and other rapidly progressive cord
diseases. Further, the arm cases have so far given but poor results.
Good cases are those in which the disease is stationary, and in which
there is sufi&cient mental intelligence to carry out physical exercises
afterwards. Then, of the utmost importance is a preliminaiy’- estimation
of the degree of paralysis which is .present in addition to the spasm.
This may be done by an intraspinal injection of stovaine, which
abolishes the spasm and allows the degree of voluntary movement to
be estimated. In operating for spastic contractions of the leg, Foerster
now holds that five roots ought to be cut : the usual ones are the
second, third, and fifth lumbar, and the two upper sacral. The
fourth lumbar is left, because it guarantees the extensor reflex of
the knee which is so very necessary for standing and walking. Un-
fortunately, there is some variability in this phenomenon, and the
second or third lumbar may be the important root instead of the
fourth ; so that now Foerster always assures himself of this point by
electrical stimulation of the roots at the time of the operation. He
gives the following table showing the effect of such stimulation.

Second sacral root — Plantar flexion of toes, and of foot
First ,, „ — Plantar flexion of foot, flexion of knee

Fifth lumbar ,, — Flexion of knee, extension of hip

Fourth ,, „ — Dorsal flexion of foot, ontward rotation of hip,

extension of knee, sometimes flexion of knee
Third „ „ — Extension of knee, adduction of hip

Second ,, ,, — Extension of knee, adduction of hip, flexion of hip

First „ „ — Flexion of hip.

Foerster himself still prefers the identification of the roots at their
exit from the dura, which involves the removal of all the lumbar
laminae. But it has been urged by various authors that this is quite
unnecessary, because all the lumbar and sacral roots can be exposed by
a laminectomy of the last dorsal and first two lumbar vertebrae. { 5 ^’e
Medical Annual, 1913, 455*) The objection to this is that the fila-

SPINAL CORD

MEDICAL ANNUAL

ments of the posterior roots lie so near together that they cannot be
accurately counted. Elsberg^ has made a valuable contribution to the
solution of this problem. He has pointed out that the ligamentum
denticulatum terminates by a forked end just opposite to the first
lumbar nerve, so that this identifies the highest of the series [Fig. 6o).
Now as the last nerve of any considerable size to be given off from
the conus medullaris is the third sacral, we have a means of recognizing
the last of the series also, and it ought therefore to be easy, if ail the
posterior nerves, from the first lumbar to the third sacral, are lifted
up on a director, to enumerate them accurately.

In France there has been a strong dis-

( j , jj ,||,ji| position to adopt Franke’s operation of

avulsion of the intercostal nerves instead of
f in tra vertebral resection of the posterior

roots, for the cure of visceral crises.®
i! ^ I i M ' I Sauve and Tine! give a very careful account

!:(/ ’ ! of the technique of this operation.

' I f order that Franke’s operation should

afford radical relief, it is necessary either
posterior root ganglion should be
" ■torn out, or that at any rate the ramus

f communicans from the sympathetic should
il/ be severed. This must be a matter of

some uncertainty, and the method is

|\|vi ■/ therefore anything but precise. More-

v! I / over, the operation has a mortality of 14

C \ cent, which perhaps compares favour-

\"‘ ^bly nith the 24 per cent which attended
^ ' ' ' ' Foerster’s operation when first performed

^deu'ilcuiLmn, "‘ld! ■''isceral crises, but is practically identi-
showing the “fork F : C- conus ; cal \rtth that of the Operation results of all

SrioH^ib^r 'u’eTout^has the cascs (64 with lo deaths). This robs

iiie den tatelf'^ ament!" Franke's Operation of its only claim to

recognition as a surgical advance. As it
was at first suggested, a mere avulsion of the intercostal nerves was
supposed to be attended b}^ no fatal risks ; but the fact is that in
the effort to reach the roots of the nerves, this safety has been lost.
Mouriquand and Cotte" point out, in a case of their own, that after
the original Franke’s operation the area of anaesthesia rapidly dimin-
ishes, and they explain how the paths of regeneration of the splanchnic
nerves are left intact. Sicard and Desmarest® put the matter clearly
when they say that Franke’s operation is either useless or dangerous.
That is to say, if it is done without close approach to the intervertebral
foramina, it will only cause transient relief. If the opera ti\'e attack
is pushed further, it involves danger of tearing the dura and opening
the pleura (Fig, 6i). They mention three cases in which fatal pneumo-
thorax was caused by the more extended type of the operation, and
this seems to have been the cause of death in most of ’the fatal cases.

NEW TREATMENT

527

SPINE INJURIES

The Possibility of Root Anastomosis Inside the Spinal Theca, — Frazier®
has made an important contribution towards progress in nerve surgery
by pointing out the possibility of intrathecal anastomosis of nerve

roots. His patient was suffering
from paralysis of the bladder as the
result of old cord injury. The lower
end of the cord was exposed, and
the first anterior lumbar nerve root
above joined to the third and fourth
sacral below. The patient made a
good recovery; four months later
he had some power of retention of
urine, and in eight months he had
acquired some expulsive power.
Kilvington has demonstrated experi-
mentally in dogs that the intrathecal
anastomosis of the ventral nerve
roots is possible. He gives a table
which shows the anatomical possi-
bilities of the method, by which the

Ft£, 61.— Shows the intimate relation ot
pleura to intercostal nerve. L, Posterior exi.
intercostal membrane ; M, Iniern.'il inter-
costal muscle. P, Pleur.a.

atrophied nerves in poliomyelitis

may be regenerated from those not affected. For example, the

eleventh and twelfth dorsal nerves may be joined to the third,
fourth, and fifth lumbar, or to the first, second, or third saci*al. If

these observations should prove to be well founded, there can be no
doubt that they open up a wide field for advance.

References . — '^Bnt Med. Jour. 1913, i, i loi ; ^Rev. de CJiir, 1913, i, 713 ; ii,
477; ^ SuYg . Gyn. and Obst. 1913, i, 117; ^Ilfid. 463; ^Amer. Jour. Med.
Sci. 1912, ii, 799 ; ^Surg. Gyn. and Obst. (Iniemat. Ahstr.)^ 1913, ii, 53 ; ’’Presse
MM. 1912, 70S; Mbid. 921 ; ^Surg. Gyn. and Obst. 1913, i, 552.

SPINE, INJURIES TO. Priestley Leech, M.D., F.R.C.S.

Pseiido-Fvacture of Transverse Processes . — Three years ago Rhys^
published a radiograph shoving an apparent separation of the left

transverse process of the
first lumbar vertebra in a
man who had received no
injury. Since then he has
seen three other cases. In
injuries to the back in work-
/siL, men’s compensation cases

such a radiograph might
easily be misinterpreted. He
has loiowledge of an instance
where a surgeon proposed
to cut down and remove

62.—Sho\ving a typical pseudo-fracture of the -ivhat had been diaSTlOSed aS
first lumbar transverse process. *>* ** o

an ununited fracture of a
transverse process. Ali the patients were adults between twenty and
sixty. In one only there was a definite history of muscular strain.

SPINE INJURIES

528

MEDICAL ANNUAL

Rhys thinks it is a developmental defect. The epiphyses of the
transverse processes are not united until the twenty-hfth year, and
in the embryo there is a costal element in connection with the trans-

verse process of the first lumbar
into a rudimentary super-
numerary rib {See Figs.
62-64).

^’ertebra which occasionally develops

Fig. 63. — First lumbar, showing Fig. 64. — Rudimentary rili.i aitached to first

gaps in both tran.s\-erse processes. lumbar vertebra, .-i/Av: T/comso/i.)

Reference. — Med. Jour. I9i3> h 1103.

SPINE, LATERAL CURVATURE OP : TREATMENT BY EXERCISES.

/. 5 . Kelleit Smith, F.R.C.S.

During the past year fresh interest in the subject of lateral curvature
of the spine has been aroused, chiefly b}- Abbott’s^ method of treating
advanced cases by over-correction and fixation with the spine in a
flexed position. The treatment of the earlier cases by means of exer-
cises scientificalh^ applied has also received attention. Success in this
latter direction depends upon three factors ; careful selection of cases ;
choice of exercises suitable to each particular patient; and skilled
supervision, with attention to all details of the patient's life.

Selection of Cases . — It is convenient to divide all cases into three
grades according to the degree of deformity : Grade i , those in which
the spine may be straightened out to normal by posture ; Grade 2,
those in which the spine ma}’ be straightened out to some extent by
posture, but in which some measure of the deformity still remains ;
Grade 3, those in which the deformity is so confirmed that radical
changes in the shape of the ribs, and inferential!}^ of the vertebras, are
palpable, and in which the alteration produced by posture is incon-
siderable.

The cases in Grade i include those often termed postural,”
" functional,” ” flexible,” curvature without bony deformity,”
” curvature without fixation,”- etc. Those in Grades 2 and 3, in
which the cur^^ature is more or less fixed, presume an increasing
amount of bony alteration, affecting chiefly the ribs to begin with,
and running on to wedge-shaped deformity of the vertebral bodies,

, Broadly speaking, cases of Grade i and of early Grade 2 give
excellent prospects of a good result by the employment of exercises.
The later the case, the more the gymnastic treatment tends to sink to
a secondary position and become an auxiliary to mechanical means of

NEW TREATMENT 529 SPINE, LATERAL CURVATURE

correction. But it is essential also in any one case to take into account
the cause of the deformity and the personal characteristics of the
patient. Cases due to weakness of the spinal structures following
quick growth or illness are quite favourable. Cases resulting from
bad habits of sitting and standing, actuated in the abnormal child by
deformity of the pelvis, difference in the standing height of the legs®
(unequal growth, flat-foot, etc.), wry-neck, errors of vision, deafness,
etc., are also promising when’ the cause is corrected. Cases with an
underlying rachitic or general constitutional asthenic (Stiller) tendency
are less favourable, and demand constant care to avoid relapse. Cases
arising from paral^’sis, emp^-ema with structural after-effects, or defects
of development in the ribs or vertebrae, must each be judged on its own
demerits. Exercises alone, or in conjunction with other methods,
ma3’ or may not result in general and local improvement.

The age of the patient, both at the onset of the deformity and at the
beginning of treatment, is important. '' Generally speaking, the
earlier the deformity develops, if it goes on for several years without
treatment, the worse the prognosis ; but where the deformity in young
cliildren is detected early and given prompt treatment, we should
expect excellent and speedy results ” (Porter*^). This prognosis must
be considered in relation to the cause of the curvature ; and it may also
be stated, as a general deduction, that in any case, the longer the period
of growth ahead during which treatment can be carried out, the better.

The patient’s mentality may have an important bearing upon the
conduct of the case. The young girl passes through a period of rapid
growth somewhere between her tenth and fifteenth years, and it is
during this period that she is especially prone to develop a spinal curva-
ture. Under ordinary circumstances, this causes little trouble in treat-
ment when detected early, and if the patient be otherwise healthy ; but
occasionally the mental powers seem to undergo an eclipse for the time
being, and this may prove a serious factor. Two types may be recog-
nized. In the first, the patient is of the “ wiry ” build, and is intellect-
ually acute bej’ond the average ; but she is incapable of sustained
mental, and therefore of sustained physical, effort ; her mental energy,
so to speak, is deficient in quantity. The patients of the second type
are usually well grown and of rather sluggish temperament, having
not much mental or physical initiative ; big-jointed, with loose liga-
ments, often presenting over-extension of the elbows, weak ankles,
flat-foot, etc. They are affected in a marked degree with that lack of
muscular sense w’hich is so frequently noticed in subjects of spinal
curvature. Both types are incapable of exerting any valuable measure
of self-help. They are cases for combined treatment — exercises for
correction of the deformity and general development, and a light
spinal support during the hours of activity to prevent relapse into
vicious attitudes.

Finally, it is desirable to draw especial attention to certain cases
which have not received the prominence they deserve, viz,, those in
'which the spinal deformity is dependent upon, or is associated with,

SPINE, LATERAL CURVATURE

530

MEDICAL ANNUAL

some visceral lesion. An inflamed or tender viscns may influence the
spinal column in two ways ; The patient may assume an habitual
vicious attitude in order to relieve pressure, or localized contraction of
muscles may be provoked b}^ reflex irritation. Both causes may be in
operation at the same time. Pain is so often referred to the back that
attention is concentrated upon the spine alone, and if the curvature be
treated without recognition of the underlying cause, no good result is
to be expected. The association between various viscera and the
regions of the spine they are apt to affect refiexly is sho\wi in the
following table (Cyriax^) ; hA^peraesthesia of the skin, with increased
tonus and irritability of the underlying muscles in those regions, are
often very marked : —

Heart . . . . . . . . 4th and 5th left dorsal segments

Stomach, cardiac end and fundus 6th, 7th, and Stii left dorsal segments
Stomach (pyloric end) and duo- (dh. 7th, and Sth right dorsal seg-
denuni ments

Small intestine .. .. .. 6tii-~iith dorsal segments

Liver and gall-bladder . . - . . oth and rih riglii dorsal segments

Kidney .. .. .. .. loih-ielh riglit dorsal segments

Spleen . . . . . . . . 91I1 and loth leit dorsal segments

Ovary .. .. .. .. 3 2tii left dorsal segment. (Also 5th

Uniibar. 2nd-^th sacral).

In like manner, the anterior abdominal muscles may also show
increased local tonus, and so affect the spine, in cases of constipation,
appendicitis and other inflammations of the intestinal tract, pelvic
pain at the menstrual periods, etc. These cases, although compara-
tively few in number, demand such particular treatment that no
examination of a case of spinal curvature, especial!}’ in older subjects,
can be said to be complete unless the state of the internal organs has
been enqiiix'ed into.

Choice of Exercise , — The number of exercises recommended for

employment in lateral curvature is very great, for the simple reason

that the groups of muscles

responsible for maintaining
the equilibrium of the spine
are brought into action in
the vast majority of the
movements of the body.
In making choice it is wise,
therefore, to consider the
exact objects to be attained,
and to this end a brief
reference to some of the
skeletal changes which take
place in the more advanced

Pig, 65. — schune of a.j\anced

cases IS necessary.

^^’hen the rotation of the

vertebrae commences in the dorsal region, the ribs on the convex side

of the curve are carried backwards, and those on the concave side are

NEW^ TREATMENT

531 SPINE, LATERAL CURVATURE

pushed forwards ; but the thoracic cage does not move round as a
whole — the sternum remains more or less in the middle line. Even in
later cases its displacement is not great ; its lower end is pushed
over to one side or other, but the upper end remains anchored by the
clavicles and b}^ the first and second ribs. Therefore the brunt of the
torsion falls upon the longer ribs on either side, and the final conse-
quence is shown in Fig, 65.

The great fact to recognize is that this bending of the ribs by the_
“ screwing-round process results in fixing the curvature long before
any serious wedge-shaped alteration in the shape of the vertebral
bodies has time to develop. In other words, the spine, which in the
earlier stages is '' whippy ” enough to present no trouble in itself, is
prevented from going back to mid-line by the deformity of the ribs.
The first object of exercise then is to overcome this fixity, to restore
the correct form of the ribs as far as possible, and to render the thoracic
skeleton so mobile as to be capable of being completely or partially
restored to its normal position. The second object is to strengthen up
the spinal muscles to such a degree that the^^ are capable of maintaining
this improved position.

Creeping Exercises.

The most important method of obtaining the first object, and at the
same time laying the groundwork for the second, is one which is little
practised in this count^}^ It has been called the creeping method,^ and
is best explained by means of a model, such as is shown in Fig, 66 A,
constructed of flexible gas-tubing to represent the spinal column, and
wire bridges to represent the pelvic and shoulder girdles respectively.
This model is placed in the “ all-fours ” attitude and pinned down to a
drawing-board. Fig. 66 B shows the principle underlying the most
useful movements of the series. Here the leg of one side and the arm
of the opposite side are moved forwards. The effect upon the spine
through the assumed obliquity of the pelvic girdle is very evident, and
that through the loose shoulder girdle may be intensified by inclination
of the head, neck, and upper part of the trunk towards the side of the
stationary arm. The total effect is the production of a simple curve
in the manner illustrated ; and this particular movement — right leg
and left arm forwards — will evidently unfold a spinal curve which is
convex to the right. Fig, 66 C shows the effect of advancing the leg
and arm of the same side. A double curve is produced, and a move-
ment such as this may be used to neutralize a contrary double curve in
the spine of tl^e patient.

Exercise I . — ^This is founded upon the principle of Fig, 66 B, and
occupies most of the patient’s attention. Plate XL VI is reproduced,
with his permission, from Professor Klapp’s handbook,^ and depicts
the subject of an advanced double curve carrying out the exercise.
The patient goes down upon hands and knees. The right knee is
advanced, not in a direct line forwards, but so that it comes to rest in
front of, or even to the left front of, the left knee. By this crossing

SPiME, LATERAL CURVATURE 532

MEDICAL ANNUAL

movement the maximum effect upon the pelvis and spine is produced.
Then the left hand is taken circling from behind forwards in a wide,
upright sweep, the trunk being at the same time pitched sideways, and
strongly inclined towards the stationary right hand. It is to be noted
that the hand is not merely picked up from the floor and held above
the head ; the “ windmill ” swing is helpful in producing the side
bending of the trunk. This part of the movement up to the point
shown in B is done with somewhat of a jerk, the patient making
a strong effort to unfold the dorsal curve, and a slight pause is made
when the arm is stretched out to its maximum. The hand is then

A B C

Fis. 66. — ^:Model to Uli^trate the creeping movements.

brought to the ground, being placed rather wide of the body (note the
position of the right hand in the figure) in order to give proper balance
for the next phase. This consists in advancing the left knee across
the right one, pivoting upon the latter to do so, and repeating the arm
and body movements towards the left side.

The exercise is by no means a violent “ plunging one ; it is rather
of the slow, sinuous type ; and although the upswinging of the arm is
done rather quickly, yet its descent is slow, and it is a good plan, in
teaching young children, to count five in seconds time during each
complete side action, so that the rate of performance comes to about
six double movements to the minute.

NEW TREATMENT

533

SPINE, LATERAL CURVATURE

The gravity of the curvature in the rib-bound dorsal region has

aiready been insisted upon. On this is based a
golden rule of practice. In cases of more than
one curve, when there is any doubt as to the
method of employing any exercise, treat chiefly
the dorsal curve. Therefore, in this exercise, the
movement which unfolds the all-important dorsal
curve is made more energetically, and is dwelt
upon a little longer, than its fellow. For this
reason, when the exercise is done in an ordinary
room, the patient should always creep round with

the dorsal convexity towards the centre, the

more important movement being given more
space thereby and being favoured by the curve
of the body as it progresses around the circle.
The patient illustrated in Fig. A, for example,
would have her right side — the side of the dorsal
convexity — towards the centre of the room, and
would travel in the direction
of the hands of a w^atch. A
patient with a left dorsal con-
vexity would travel in the
opposite direction.

It will be evident to the
student, after a little experi-
ence, that the unfolding effect
of this exercise may be located
chiefly in the dorsal or in the
lumbar region, according as the
shoulder or the pelvic girdle is
the more strongly side-tilted. The progression
along the exercise floor of a patient with a marked
double cuiv'e is shown in diagram in Fig. 67.
Here the maximum effect in the iirst step is

thrown so as to treat the dorsal curve, the

Fig. 67. — Diagraiii of tlie
first exercise in a case of
double cun’ature.

shoulder girdle being mainly acted upon. In
the second step the pelvis is the more strongly
tilted, with the result that the abnormal lumbar
curvature is erased.

t' In treating patients with simple total curvature
presenting some amount of fixation, it is some-
times advisable, especialh’ in the beginning, to
employ the strong corrective action alone. In
this case, the following movement consists of a
simple pace forw'ards, during which the advanc-
ing knee is not crossed over its fellow and the
arm is not swung aloft, and w^hich merely serves

to bring the patient into position to repeat the correcti\^e effort.

SPINE, LATERAL CURVATURE 534 MEDICAL ANNUAL

Exercise II. — This is a variation of No. I, but places more strain
upon the erector spinas muscles. The hands rest, thumbs backwards,
upon the iliac crests, and the shoulders are kept braced well back.
The trunk leans forwards from the hips, and as the patient progresses
on the knees is inclined laterally towards the side of the advancing
foot {Plate XLVIIj Figs. A and B). In order to
preserv^e the balance, the knees advance in a
direct line, without any of the crossing move-
ment advisable in Exercise I. In this exercise
also, the movement which unfolds the dorsal
curve is made more strongly than its fellow, and
the same rule of travelling with the dorsal con-
vexity towards the centre of the room applies.

Exercise III. — This is founded upon the prin-
ciple of Fig. 66 C, i.e., the limbs of the same side
are advanced together. It is of most use in
those cases of double curvature which present
also a marked degree of
kyphosis.

The first thing to notice
is that it is carried out
with the thorax kept low
to the ground. Hence it
is known as the low-creep-
ing movement, in contra-
distinction to Exercise I,
•which is the high-creeping
movement XPlate XLVI,
Fig. B). The object of
keeping the thorax low is to attack the kyphosis :
with the pehds high and the shoulders low, the
spine sags in such a way as to correct this, and
the effect may be increased by holding the head
well back. Plate AXFJJ, Fig. C, represents the
strong corrective movement in a case of double
cuiwature convex to the right in the dorsal
region, and reference to Fig. 66 C will help con-
siderably in its interpretation. Starting from the
hands-and-knees position, the left knee is first
moved forwards, and the right leg is then
stretched backward and swung across to the left
as far as it will go. The result is to side-tilt the
pelvis in such a fashion as to unfold the lumbar
curve. The left arm is then advanced and the
trunk strongly bent to the right. This movement unfolds the dorsal
curve. Thus the total cnect is to correct the deformity by reversing
both curves by mo\'ements which, in a normal spine, would produce
a double curvature convex to the lejt in the dorsal region.

NrW TREATMENT

535

SPINE, LATERAL CURVATURE

The patient makes both phases of the movement very strenuously,
the pelvis being side-tilted to the right, and the shoulder-girdle turned
to the same direction, as much as possible, and this position is main-
tained for a few seconds. The next pace forwards is a simple one, and
is made by advancing the right knee and right hand without any
crossing of the legs or much curving of the trunk, its object being
merely to relax the tension on the spine for the time being and to bring
the patient into position to repeat the stronger corrective movement.
Fig. 68 shows in diagram the progression of the patient. In dealing
with a case of double curvature convex to the iert in the dorsal region,
the sides of the strong and weak movements in the above description
would, of course, be reversed.

This exercise is a difficult one, and the patient requires some practice
in Nos. I and II before proceeding to it. When carried out to perfec-
tion, the front part of the bod}’ travels along quite close to the ground,
with the arms spread out and elbows up, much in the same style that
a crocodile’s body is carried along between its own forelegs.

The exercises may be carried out in a room, corridor, or an}-’ place, in
short, with a smooth floor free from splinters. The patient is provided
with a loose g}nnnasium costume, the knees are protected by knee-caps
of thick boiler felt tied on with tapes, and the hands may be similarly
protected by a pad of felt worn on the palmar aspect. Gymnasium
shoes, the toes of which ma}’ be strengthened up against friction by a
cap of leather, complete the outfit.

Patients who are undergoing treatment, exercise for one hour in the
morning, and for any time up to one hour in the afternoon. Forty
minutes of this hour are devoted to the creeping exercises, the greater
part of the time being occupied by No. I, and the remainder by an
occasional few minutes of No. II, and also of No. Ill, when the case is
such as to demand it. A brief rest is taken at suitable intervals, tlie
patient lying prone on the floor and resting the chin on the folded
hands. Such a position of rest {Plate XLVllT F‘g. B) is valuable for
most spinal cases, especially for those with a tendency to k}'phosis,
and is the position adopted for at least half an hour at the end of
each exercise period. Reading, and some other light pursuits, may
be practised if a cushion be placed under the arms.

The latter portion of the hour is devoted to straight work ” exercise
calculated to act more directly upon the spinal muscle groups. These
are considered below. As the patient improves, and the thoracic
framework grows more flexible, and more capable of being held in
correct position, tliis straight work ” becomes the more important part
of the programme, and a greater proportion of time is allotted to it.

In early cases, where there is no fixed distortion of the thoracic
framework, the straight exercises are the more important from the
begimiing, but the creeping method — chiefi}^ Exercise No. I, with
equal movements on the two sides, i.e., “ symmetrical creeping” — is
highly advisable at first, in order to strengthen up the muscles by
gentle means, and so prepare them for the more strenuous eflorts
which follow.

SPINE, LATERAL CURVATURE 536

MEDICAL ANNUAL

Before discussing the latter, it will be well to point out some of the
advantages which ma}’ be claimed for the system of exercises already
described : —

I. In the all-fours position the spine is relieved of weight, and is
automatically straightened out as much as possible. The general rule
in these cases, that all exercises should be performed with the spine in

the best possible position, is thus

Fig. 69. — Spine in erect position on left, with
'the subject on ali-fours on right.

obeyed. Fig, 69 shows a record of
the spine of an overgrown youth,
17 years of age, whose trouble is
due to a left leg three-quarters
of an inch shorter than the
right, and to a year’s close desk-
work. On the left is the chart
of his spine in the erect position,
the vertical measurements being
taken by calipers from a base-
line drawn through the posterior
superior iliac spines. On the
right is a tracing obtained from
him on all-fours, b}^ placing a
dot of printer’s ink on the tip
of each spinous process, and
taking a transfer on a strip of
linen. The spine is shown to be
straightened out, and incident-
ally the production of his triple
curve from a single left convex
curve is analyzed.

2. The movements are kept
within the limits of the physio-
logical excursion of the parts ;
there is no acrobatic distortion.
The muscles on both sides of the
spine are dealt with — ^those on
the convexity of the curve
Avhich, hypertrophied at first b}^
their efforts to restore the spinal
balance, finally become stretched
and weakened ; as well as those
on the concavit}^ of the curve,
w’hich become contracted.

3. The exercise is not severe, and patients soon find themselves able

to keep it up for full time without fatigue or muscle-soreness. The

morbid curves are thus unfolded some two hundred times, or more,

at each session, and entirely by the patient’s own muscular efforts.

In both respects the great superiority over the methods of treatment

b}^ puUing by bands, or by bending the patient b}' manual help, either
with or without some supporting apparatus, is evident.

Fig. ZJ.— Movement to the right m
Exercise II.

Fig. .-1 .—Movement to the left in
Exercise II.

Fig. C . — The low creeping movement emploj'ed chiefly in double cur\'es
with marked kyphosis.

MEDIC A L -1 AW UA L. iqu

PLATE XLVIIL

SCOLIOSIS —continued

.. — ^Tlae starting position for straight work (standing).

Fig. B . — The position of rest.

MEDICAL AXXUAL, iqi4

C . — The swimming movement in the prone position.

PLATE XLIX.

S C O L I O S i S — continued

Fis;. A . — Fists forward in Exercise No. II. Fiq. B . — Bending fonvard in

Exercise No. III.

MEDICAL AXSUAL, 1914

PLATE L.

S C O L I O S I S — cofitiiiuvii

Fig. A . — ^The resting position on the bench.

Fi^

B . — ^The starting position of Exercise ZSTo. I on the bench.

Fig. C . — The starting position of Exercise No. Ill on the bench

MEDICAL AN^-UAL, 1914

NFAV TREATMENT

537

SPINE, LATERAL CURVATURE

4. It is efficacious : the spine is acted upon at both ends : and it is
sometimes capable of producing extraordinary improvement in the
most unpromising cases. Fig. 70 shows the tracings from a much-
deformed adult of twenty-six years, wdth a progressive downward
history, despite the use of mechanical supports, of ten years. The
tracings are of the sky-line " of the back at the level of the sixth
dorsal spine, and are taken with a wax strip with the patient in the
usual position, i.e., bending forwards with the trunk at right angles to
the legs and with the arms hanging loosely down. They are taken in

each case between points on either side of the spine which occupy the
same horizontal plane, and therefore give a true picture of the contour
of the posterior part of the thorax. The continuous line shows the
condition at the commencement of treatment, the interrupted line the
improvement in four months. In such an advanced case a cure was
out of the question, but the exercises were quite successful in relieving
constant aching pain and in restoring the patient, with the help of a
light supporting apparatus, to a life of healthy activity.

Straight Work Exercises.

The object of the second series of curative exercises (“ straight work
series) is, as before said, to strengthen up the spinal muscles to such a
degree that they are capable of maintaining the improved position
rendered possible by the first series. The movements about to be
described do not belong to any one particular system, and are selected
for their simplicity and the efficacy of their action upon the spinal
muscle-groups. They are carried out in four positions — standing,
sitting, prone on the floor, or on a bench — but they have all the same
root idea, viz., the spine being' stiffly held, the trunk is (i) Either made to
perform movements of fle.x ion and extension at the hip joints whilst the
arms are kept still (7, III, V) ; or (2) Is held in the position of strain
{i.e., flexed on the hips when sitting or standing, extended if prone)
whilst the arms are active {II, IV, VI). The standing and sitting
positions are especially valuable in cases where the patients are very
deficient in the proper sense of muscle balance. As a general rule, the
prone positions are the most useful, and that on the floor is the easiest
for the beginner to learn.

In all the exercises the spine must be stiffly held, so that the lumbar
curve becomes as pronounced as possible and the erector spinae muscles
feel hard to the touch all the time the patient is working. Whate\'er

SPINE, LATERAL CURVATURE 33S

medical annual

position is taken up, the programme is just the same as regards details
of movements, which may be listed as follows : —

No.

Trunk

1 Arms

* Flexion and extension

1 B}' sides

Flexed, if standing or sitting
Extended, if prone

Fists to shoulders

Shoot fists forwards
Recover

III

Flexion and extension

i Hands to back of ears

Flexed, if standing or sitting
Extended, if prone

' Fists to shoulders

' Shoot fists outwards

Recover

j Flexion and extension.

i Stretched a.bove head

Flexed, if standing or sitting
i Extended, if prone

Swimming movements
i (breast stroke)

Tne ternis lle.>:icn a>id e:ctens:on as applied to the trunk refer to its position m relation to the thiyli'b.

Each exercise is carried out six to twelve times, and a series in one
vertical and one prone position — e.g.,. standing and on the ground, or

sitting and on the bench — is gone through at each session. A rest of
a few moments is given after each exercise. There must be no hurrying,
and each phase of an exercise must be marked by a slight pause. This
is insured by the instructor giving words of command for the slower
movements, and counting the quicker movements in seconds time.
For example, No. II in standing position would be conducted thus : —

Instructor.

Patient.

Attention

Forwards bend
Prepare

In seconds time
Repeat movement
six times

As yon were

. One
} Two
j One
1 Two

Assumes starting position i Pints
XLVIII, Fig. J)

Trunlc forwards

Fists to shoulders

Fists shoot forwards {Plate XLIX,

Fists back to shoulders

Fists shoot forwards

Fists back to shoulders

Patient drops hands and stands erect

Again, No. Ill on the bench would be as follows : —

Instructor.

Patient.

Attention

Repeat
movement
six times

As you were

I Dowmvards
‘ Upwards
I Down wards
* Upwards

Rises iroru the resting position
\ Plats L, Fig. A'., and at once
assTimes the position ot exercise
[Plate L, Fig. C).

Trunk is hexed at hip joints
Trunk recovers
Trunk is hexed at hip joints
Trunk recovers

Patient resumes attitude of Plate
L. Fig. A).

NEW TREATMENT

539

SPINE, LATERAL CURVATURE

In the swimming movements (No. VI) the instructor times the quick
forward dart of the hands and allows a suitable period for the deliberate
backward sweep. Respiration must be carefully trained in this move-
ment. Inspiration is made through the nostrils, with closed mouth,
as the arms go backwards. Expiration is made forcibly and audibly
with the mouth open as the arms shoot forwards.

It now remains to note briefly certain details of each position : —

1. Standing. — Plate XLVIII, Fig. A, gives the starting position.
The feet are apart, knees quite stiff, trunk inclined slightly forwards
^vith the back well arched, arms by the side, shoulders down, head
erect. In Exercises I, III, and V, the trunk bends forwards and
backwards from this position with the arms by the side, to the back of
the ears, or stretched above the head, as the case may be. Plate
XLIX. Fig. B, illustrates No. Ill, and shows the patient during the
act of bending forwards. Notice that the knees are rigid, the back
is well arched, and the erector spinae thrown into prominence. In
Exercises II, IV, and VI, the arm movements are made with the trunk
held inclined forwards. Plate XLIX, Fig. A, illustrates No. II.
Notice again, that the knees are rigid and the body well arched.

2. Sitting. — The patient sits forward on the edge of a chair or stool,
with the feet on the floor and the back held stiff. The movements are
made exactly like those in the standing position, but in Exercise I, with
the arms down, the hands grip the edge of the front or sides of the seat.

3. Prone on the Ground. — The patient lies on a rug, and the feet are
kept down by a strap or by the instructor’s hands. In Exercises I,
III, and V, the trunk movements are necessarily confined to a rearing
up ” from, and a return to, the prone. This is done with the arms in
their appropriate positions — by the sides, with the hands to the back
of the ears, or stretched forwards to fullest extent, as the case may be.
In Exercises II, IV, and VI, the trunk is held as in Plate XLIX, Fig.
C, which illustrates the swimming movement.

4. On the Bench. — The bench should be about 20 inches high. The
patient lies prone with the pelvis at the edge thereof, and the feet
are kept down by a strap passing over the ankles. Plate L, Fig. A,
shows the resting position which the patient assumes between the
exercises, and from which the starting position of any particular
exercise is taken up upon the word of command. Plate L, Figs. B
and C, illustrate the starting positions of Exercises I and III, and from
these positions the trunk, held stiffly all the time, is bent from the hips
towards the ground as far as possible, and then restored. In Exercises
II, IV and VI, the trunk is maintained in position similar to that
shown in Plate L, Figs. B and C, whilst the arm movements are
carried out.

Personal Supervision. — It would seem superfluous to insist upon the
necessity for this, were it not for the fact that the treatment of cases of
lateral curvature by exercises is too often delivered entirely into the
hands of certificated medical gymnasts, whose results, owing to their
inelastic methods, are largely a matter of chance.

SPINE, LATERAL CURVATURE 540

MEDICAL ANNUAL

Any therapeutic measure is valuable in proportion to its range of
application and its exact adaptation to a particular case ; and this is
just as true of the use of exercises in spinal deformities as it is .of the use
of a powerful alkaloid, or a vaccine, or the surgeon’s knife, in other
maladies. It is necessary to take into account the fact that lateral
curvature occurs, as a rule, in what we may call a complex patient, and
that surgeon will have the best results who submits each case to the
most careful anal3^sis, and w’ho gives the strictest personal supervision
to whatever method of treatment he may adopt.

In man^^ cases, the ideal method is to place the patient at a school
where the malady is understood. The atmosphere of discipline is
good, school-work and rest can be dulj" proportioned, and the presence
of other pupils undergoing treatment stimulates interest and avoids
monotony". A nurse trained in one’s own procedure pa^'s daily ^’isits
and superintends each period of exercise, but the surgeon directs the
whole conduct of the case ; he initiates every new movement, and sees
that it is carried out properh", and he prescribes all such accessoxy^
measures as ma^’- be necessary". The dominant factor of the patient’s
life is the cure of the spinal deformit\% and ever\dhing must be subser-
^dent to this.

The management of the exercises has alread\’ been described. It
ma\^ be added that the patient, who is generalh" a weakly girl, cannot
be expected to take the full time to begin witli, but with the s^’^stem
advocated here, the capacity to do so is soon gained. At first, not only
the ph\’sical but also the mental processes become fatigued, and a short
c^^cle of exercises carried out with full intent is worth many hours of
perfunctory movements. It is better, as a matter of training, to
occup\" the full hour, interrupting the exercises with occasional rests,
than to shorten the total time occupied. The surgeon must regard
the exercises as a therapeutic remedy', and must beware of an overdose.
Overworked muscle becomes as feeble as disused muscle, and should
the condition of staleness ” arise, the patient must be given a holiday"
for a few da^’s.

Attention ma}' now be drawm to the following points, wliich will
serve also to indicate the tj^pe of discipline necessar\' : The maintenance
of genei'al health is of prime importance. Slight anaemia, not alwaj^s
obvious, is a frequent cause of muscular feebleness. In man\^ cases of
malnutrition, oil (cod-liver or petroleum) is helpful from the fact that
it is second onh’ to the natural HCl itself (often deficient in such cases)
in producing secretin, and thus stimulating intestinal digestion. The
improvement of the scoliosis almost invariabh’ results in improvement
of the general health” (Porter). Writing and reading at an ordinarv
desk, piano and violin placing, and ail occupations involving strain and
encouraging faiilt\’ attitudes, must be foi’bidden. Any ” brain fag ” is to
be avoided, but eas\^ studies mat' be carried out in the resting position,
or at an adjustable desk of the Glendenning type. All attention should
be given to the abnoniial region. Other gt'mnastic exercises are not
to be taken, but the daih' walks and attendances at meals should be

NEW TREATMENT

541

SPIROCH/eXOSfS

used as drills in training the patient to a sense of upright carriage.
Towards the latter end of the treatment the second exercise hour may
be occupied by singing or by swimming, and cycling may be allowed as
an outdoor exercise. The spine must be relieved of weight as much as
possible. Therefore bed must play an important part in the patient’s
life : ten to t\velve hours are not too much. The patient should lie on
the back, or on the side of the dorsal concavit5^

References. — Med. Jour. 1913,!; -'E. Gillespie, Clm. Jour. 1913,
63; ^The Child, I9i3> Feb.; ^Trans. Amer, Orthop. Assoc. 1913, May;
°Joiir. Sci. Phys. Training. No. 12; ®Kellett Smith, "'Lateral Curvature,”
John Wright & Sons Lti, Bristol; Brit. Med. Jour. 1912, ii, 1466; The
Child, 1913, Apr.; Funktionelle Behandlung der Skoliose,” Fischer, Jena.

SPINE, OSTEOMYELITIS OF. Priestley Leech, M.D., F.R.C.S.

Strong^ reports eight cases of this disease, which is rare, but not, he
thinks, so rare as is generally believed. The actual cause is the Staphy-
lococcus aureus ; a history of injury is common ; a whitlow has also
been the cause.

Diagnosis. — The disease may and often does closely resemble Pott’s
disease, especially if it runs a subacute or chronic course. Kirmisson
mentions the following points of distinction : the abscess of Pott’s
disease most often appears extemall}- in Petit’s triangle, and is
roundish, whereas that of osteom^^elitis spreads along the vertebral
column and is fusiform or oblong. Especially important are e\’idences
of secondary circulation in the skin round the abscess, owing to septic
thrombosis in the spinal veins.

Treatment. — Immediate operation offers the best prospect of cure,
but opinions differ as to the details. Some advise opening of the
abscesses and removal of the necrosed bone, while others advise
wiping out with carbolic acid, neutralizing with alcohol, and leaving
the bone alone.

Reference. — '^Lancet, 1912, ii, 1576.

SPIROCHiETOSIS. Leonard Rogers, M.D., F.R.C.P.

G. H. F. Nuttall,^ discussing our present knowledge of this class of
diseases, begins with a description of the Spirochceia anserina of geese
and fowls, and its transmission through the bites of a tick, the Avgas
persiciis, which is most infective if kept at a temperature of 30° to
35^ C. after feeding on a diseased bird. The spirochastes enter the
ccelomic cavity and reach the IMalpighian tubes, where they form
numerous coccoid bodies, as well as in the lumen of the gut and in the
coxal gland. In the act of feeding, the tick often exudes excrement
and secretion of the coxal glands, and the infection ma}^ thus reach the
wound made by its bite and produce infection. From the Malpighian
tubes the coccoid bodies pass to the eggs and infect the next generation,
by whom the disease may be transmitted.

In the case of human relapsing fever, Livingstone in 1837 was the
first to report that the disease is transmitted by the bites of a tick now
known as the Orniihodorus moubata ; in 1905, Dutton and Todd, and

SPlROCHiCTOSiS

542

:SIEDICAL ANNUAL

soon afterwards Koch, proved the correctness of this observation, and
demonstrated that the offspring of infected ticks also conveyed the
disease. From 5 to 15, and at times 50 per cent of ticks may harbour
the parasite, especially along caravan routes in rest-houses, which are
frequent sources of infection. As the tick is Imorni to be much more
widely distributed in Africa than the fever, there is reason to fear
extensions of the latter with opening up of trade routes. The fever
has been frequently transmitted hy ticks to rats, mice, and monkeys,
and accidentally to workers in European laboratories. Moller infected
ten out of twelve successive monkeys on which one lot of ticks had fed,
80 per cent of these animals dying of the disease. A tick has been
proved to convey the disease eighteen months after its first infective
meal of blood. Some ticks acquire immunity-' to infection. Leishman
was the first to prove the infection through the excreta and coxal
secretion in this form of spirochastosis, and traced the infection of the
eggs through the iSIalpighian tubes. A number of strains of spiro-
chaetes of relapsing fever of different origin have been described ; but
it is doubtful how many of them are distinct species, and O. moubafa
has been found capable of harbouring the infection of several of them.

Other insects besides the tick have been shown to transmit spiro-
chaetosis. Thus, in 1897 Tictin infected monkeys with the contents
of bugs twenty-four hours after a feed on relapsing-fever blood ; and
in 1902 the spirillum was found to siiryi\'e as long as thirty days in
bugs. In 1907 IMackie proved that lice could transmit relapsing
fever of Bomba}", and traced the organisms to the gut, ovary, testis,
and Malpighian tubes of the insects. A year later Sergent and Foley
found lice carrying the infection of relapsing fever in North Africa ;
and in 1912 NicoUe showed that the organisms disappear from the
gut of lice after twent}'-four hours, to reappear after about eight to
twelve days, when their body contents smeared on excoriations of the
skin, produced infection. They also proved that the eggs and offspring
of lice may be infected, so that lice crushed on the person during
scratching might infect human beings.

H. Noguchi=^ records the successful cultivation of several varieties of
spirochastes of relapsing fever by the same method that he employed
for the T, pallidum . A piece of fresh tissue, such as rabbit kidney, is
placed in a sterile test-tube, a few drops of the citrated blood from
the heart of an infected mouse or rat are added, and about 1 5 c.c. of
sterile ascitic or hydrocele ffuid poured in. The tubes are incubated at
37° C., with or without a layer of sterile paraffin oil on the surface of
the fluid. Subcultures have been obtained, in one case up to twenty-
nine passages, by transferring half a cubic centimetre of the first
tube, preferably with the addition of a little normal rat*s blood. On
examining the living cultures with the aid of dark -ground illumination,
he observed longitudinal dhision in every case, while the more usual
transverse division was rarely seen.

G. V. Browse^ describes what he takes to be a special form of -relapsing
fever met vdth at Quetta, on the north-west frontier of India. In its

XEW TREATMENT

543

SPLEEN, CYSTS OF

course and blood changes it resembles the Ahicaii more closely than
the European variety, but occurs in a ver^* diflerent climate. During
a 3’ear’s observations, the spirillum was found in eighteen cases, which
seemed to follow hve to ten dat's after warm spells of weather. The
cases were almost confined to overcrowded followers* quarters, but
were irregularly distributed in them. The disease was mild, onset
sudden, febrile jDaroxysms short, two to three days at first, decreasing
to a few hours in later relapses, which numbered from one to six, giving
ver}^ irregular temperature charts. The blood-counts were made by
Rogers’ method, and showed but slightly marked total and relative
polynuclear increase, together with some large mononuclear excess,
although antecedent malaria did not appear to be its cause, thus difier-
iiig from the typical changes of relapsing fever other than the African
form. Both lice and bugs were present, also a tick said to be O.
tholozani, and one Argas perslcus was found, but he was unable to ascer-
tain which was the carrier of the infection. He found the thick-drop
method vert" useful in detecting the spirochcotes when they were
scanty. Frequently found during the apyrexial intervals, the\’ did
not dife' in appearance from the usual descriptions. A. jM. Jukes-*
describes a somewhei-t similar type of spirillum fever in the Darjeeling
hills, but which was very fatal.

References. — Johns Hop, Hasp. BitiL 1913, 33; “Munch, nud. Woch.
1912, 1937 ; ^Ind. Med, Gaz. 1913, 3S7 ; Mhid, 222.

SPLEEN, CYSTS OF. Sir Berkeley Moymhau, 3/,S., F.R.C.S,

Harold XJpcott, F.R,C,S,

Etiology. — Cysts of the spleen may be classified as dermoid,
parasitic, and non-parasitic. There is only one recorded case of the
first. Echinococcus is the most frequent variety of parasitic cyst,
and occurs in regions where hydatid disease prevails. In about half
the recorded cases the spleen was the only organ affected.

Fowler’s article^ is chiefiy devoted to a study of the non-parasitic
cysts. He rejects the usual subdivisions of haemorrhagic, serous, and
l^^mphatic C3"sts, and suggests a classification which will indicate the
mode of origin of the c\^st : (i) Traumatic (hsematoma, secondar^^
serous cy'sts) ,* (2) Infoiiation (traumatic or inflainmator}’ inclusions of
peritoneum) ; (3) Dilation c^’sts (ectasis of splenic sinuses) ; (4)

Disintegrative (infarction, etc.) ; (5) Neoplastic ; (6) Degenerative

c\’sts (arising from secondary’ changes in new growths). JMost of the
cases occurred in middle life, and in six cases there seemed to be some
relation between pregnanc^^ and cyst formation. Tliree of these were
blood-cysts, and Fowler suggests that they were possibly due to second-
ary iisemorrhage in an infarct. The common factor in the etiology of
cysts of the spleen is trauma. The extensi\’e multilocular cyst forma-
tions in the spleen are of considerable interest. Such a one is figured
by Fowler {Plate LI), who explains the condition as a dilatation of
l^TOph or blood sinuses.

Symptoms. — The principal are pain, pressure phenomena, and

SPLEEN, CYSTS OF

544

MEDICAL ANNUAL

tumour. Pain, in the left hypochondrium, is of a heavy dragging
character, closely resembling that commonly attributed to a movable
kidney. In other cases pain may be absent, or it may occur in repeated
attacks, probably due to peritoneal reaction. Pressure s^unptoms
take the form of digestive disorders, and are probably due to displace-
ment of the stomach and intestine. An elastic tumour may be palpable
to the left of the umbilicus.

Treatment. — If not contraindicated by the presence of extensive
adhesions. Splenectomy is the operation of choice. If this is imprac-
ticable and the cyst is subcapsular, its wall ma}" be excised and its
floor destroyed by cautery.

Resection of a portion of the spleen bearing the cyst is rarely justifi-
able, as these cysts are rarely peduncleated, and the danger from
haemorrhage is great. Incision and drainage or marsupialization are
better suited to the treatment of parasitic cysts, when more ladical
methods are not feasible.

Reference. — K 4 vn. Suyg . 1913. i, 65S.

SPLENOMEGALY. (See also Polycvthjemia ; Spleen, Surgery of.)

Herbert French, il/.D., F.R.C,P.

Splenic ancsmia nia}^ or may not be a clinical entity ; it is at any
rate an ill-defined disease, for many cases that are thought at one
period or another to be t^’pical examples, ultimately turn out to have
been some commoner malady — especially cirrhosis of the liver — in a
stage at. which splenomegaly and anaemia attracted main attention,
the other and more usual symptoms not appearing until after the lapse
of months or years. There are many, however, who believe splenic
anaemia to be a real disease, recognizable by its clinical s^unptoms ;
and there is increasing evidence to show that Excision of the Spleen is
beneficial, or even .actual^ curative, to the patient. The clinical
features presented by 18 cases in which this procedure was adopted
have been summarized by Giffin ; 12 of the patients were females, and
6 males ; the youngest w^as twenty-two, and the oldest fifty-six. The
average age was thirty-seven.

Enlargement of the spleen was noted in one case twenty years before
operation ; in another fifteen ; in a third ten years. In 8 instances
splenic enlargement had been noted less than a year preceding operation,
and in the remaining 7 from one to seven years. It is probable,
however, that splenomegaly had in reality been present for a longer
time in many of these cases. In 14 the enlargement of the spleen
had definitely preceded the appearance of anaemia. In no case did the
occurrence of anaemia clearly precede splenomegaly. The recorded
measurements of all the spleens show them to be either large or enor-
mous. Ail save one, which lay transversely, reached below the level
of the navel, and 7 extended into the left iliac fossa and beyond
the median line. In none did the long axis extend diagonally across
the abdomen, but lay almost entirely to the left of the median line.
It is interesting^to note that one spleen lay very high, and the enlarge-

NEW TREATMENT

545

SPLENOMEGALY

merit extended transversely into the epigastrium, only one-eighth of
the spleen being palpable below the costal margin.

The anaemia was of the secondary type, and there was an absence
of leiicocytosis. Differential counts were not distinctly abnonnaL
Hemateniesis occurred in five cases ; in four of these it was severe.
In one case it had occurred every year for fifteen years. Blood in the
motions was also present at these times. In one case of Banti s disease,
in which hemateniesis had been severe for nine months, the hremoglobin
dropped as low as 20 per cent. This patient was still well tliree and a
half years following the operation. There was no instance of bleeding
elsewhere than from the gastro-intestinal tract.

The frequent occurrence of pain in the region of the spleen is note-
worthy ; it is probably caused b^’ the. perisplenitis which is so commonly
present. Infarction may also be a cause of pain. Fever was present
in only two of the cases while under observation, and was not over 100-.
Two patients presented conditions simulating splenic ansemia, and
suffered from high fever, chills, and prostration in periodic attacks ; but
one of them at exploratory operation showed an advanced cirrhosis
of the liver ; the other had splenectomy performed, but at operation
evidences of gall-bladder disease were found, with many upper abdo-
minal adhesions, and the spleen was not of enormous size. In this
patient there were periodic and abrupt elevations of temperature to
105°, and at the same time the size of the spleen increased and upper
abdominal pain of moderate severity was complained of. The con-
dition of the spleen seemed to be secondary to a widespread abdominal
infection, and not primary.

Diarrhcea had been present in only four cases. A history of malaria
was obtained in only four cases, in tw’o of which there may have existed
some direct etiological relationship. It is probable that chronic malaria
produces a condition which eventually' cannot be difi'erentiated clinically
from splenic anaemia. A history' of lues was not obtained in any of the
cases. The Wassermann reaction was done on several of the more
recent cases, and was negative.

Cirrhosis of the liver was diagnosed at operation in five cases. In
one additional patient, clinical evidence of cirrhosis of the liver
developed a year after, and the patient died later. No case showed
abdominal fluid without evidence of change in the liver at operation.
Jaundice was noted during the course of the disease twice, once with
and once without evidences of cirrhosis.

Death followed splenectomy ttvice ; of the 16 patients who
recovered from operation, 12 were in excellent health at the time
of reporting after periods varying from six months to seven y^ears ;
2 were improved ; i improved for several months ; but later developed
ascites and died three y'ears after operation, with symiptoms of hepatic
cirrhosis ; and i died two and a half years after operation — the cause of
death unknown.

‘Eppinger- records ten cases of splenectomy which seem to throw
some new light both upon the phy’siology of the spleen and upon the

SPLENOMEGALY 546 MEDICAL ANNUAL

nature of certain haemolytic diseases, especially haemolytic jaundice
and pernicious anaemia. He is, we think, the first to have treated
pernicious ancemia by excising the spleen, and states that the results
have been good.

He also suggests that in cirrhosis of the liver the spleen plays a much
more active part in the production of the pathological changes than has
hitherto been recognized ; and that here also splenectomy is good
treatment if the disease can be diagnosed in the early stages. Tansini
and Moron e® record a case of splenectomy in the ascitic stage of
cirrhosis of the liver ; the operation was undertaken in their patient
on account of acute abdominal symptoms due to splenic thrombosis ;
the result was remarkable in that it led to apparent cure, or at any rate
to the subsidence of all symptoms, in a patient suffering from cirrhosis
of the liver that had reached the ascitic or last stage.

References. — K 4 mer. Jour. Med, Sci. 1913, i, 7S1 ; -Bert. klin. Woch.
1913, 1572 ; ^Rev, de Chiv. 1913, ii, 263.

SPOROTRICHOSIS, Herbert French, M.D,, F.R.C.P.

Hamburger^ discusses the incidence and clinical symptoms of sporo-
trichosis in man. He classifies the clinical varieties of the lesions as
follows : (i) Localized sporotrichosis, with sporotrichotic chancre and

ascending lymphangitis and local lymphadenitis. (2) Disseminated
gummatous sporotrichosis ; multiple subcutaneous nodules distributed
without systematic arrangement throughout the body ; early small,
hard, painless, round masses ; late small and large soft cold abscesses ;
no ulceration. (3) Disseminated ulcerative sporotrichosis ; multiple
polymorphic ulcerations of the nature of tuberculous, syphilitic,
ecth^miatous, rupial, or furuncular lesions, or a mixture of these.
(4) Extracutaneous sporotrichosis, with localization in mucous mem-
branes, muscles, bones, joints, ocular tissues, syno\'ial membranes,
kidneys, and lungs.

Sporotrichosis may affect voluntary muscles in two wa\'s (]Moure
and Baufle*-) : (i) By direct extension from the skin or subcutaneous
tissues ; (2) As a primary condition ; the latter may affect onh^ a
single muscle, the triceps for example, and the diagnosis may be
difi&cult. The mass passes through the three stages of tumour, soften-
ing, and suppuration, and it is apt to suggest in succession fibroma,
gumma, and tuberculous cold abscess. The diagnosis can only be made
by careful bacteriological investigations. ]Moure and Baufle record a
case in point in which surgical measures were adopted not only without
success but with actual detriment, whereas cure was effected quickly
on giving iodides. It is unfair to the patient to conclude that the
condition is syphilitic because it heals under iodides ; the Wassermann
test should be carried out and found negative.

Diagnosis. — Hamburger believes that the condition is by no means
so uncommon as might be expected from the literature, many cases
escaping diagnosis. He says the features which are helpful in the
differential diagnosis of sporotrichosis may be grouped as follows :

Fig. C.

/v\,, J,— Three-day gro\,tit o:-! j per ccn: gluc..-e agar: dram; oil immersion.

Fig. B. — Seven-day grou’th on a per cent gluco'-e agar.

/;,V (7. — Four-day-old culuiiy on p’ain bouillon; methylene blue; oil i^u^ler^;o.^ ; >hu\\ing
nn’ceiium.

»V. P. — Fuur-day-old colony in plain huuilFn ; meLh\ lene blue ; lou pouer; show ing Niinilarity
to actinomyce.s.

MEP ICA L A XX U A L , IQJ 4

NEW TKKATMENT

547

SPUTUM

There is local and general eosinophiiia. Eosinophils have been noted
in the initial chancre in the nodules, in the pus from the broken-down
nodules, and in the circulating blood. The cultivation of the organism
on artificial mediums is of great diagnostic import, the growth of
sporofrichiuni being characterized by its slow initial appearance ; its
ready growth on 2 per cent glucose agar at room or incubator tempera-
ture ; its raised corrugated appearance on slant agar, and its radiating,
flower-like appearance in stab culture ; its brownish-black pigment
production in old cultures and on 4 per cent glucose agar ; its branching
septate mycelium and pear-shaped spores {Plate LI I}.

Treatment. — Potassium Iodide should be administered internally
in increasing doses, as high as 6 grams a day and even more, and the
local lesions should be dressed with a weak Iodine-Iodide Solution
(water, 500 grams; potassium iodide, 10 grams; iodine, i grain).
Finally, the ulcerated points should be cauterized with Tincture of
Iodine. The prolongation of general treatment for a month after
complete apparent recovery, is indispensable to prex’ent relapse and
recurrences.

Keferences. — ^Joitr. Amer. Med. Assoc. 1912. ii, 1590; '^Presse Mh^ .
1912, go2.

SPRUE. Leonard Rogers, M.D., F.R.C.P.

A. Castellani^ records three cases w'hich were clinically sprue, even
including the mouth lesions in one, but which on investigation proved
to be associated wdth a Flexner-like bacillus, strongly agglutinated by
the patient’s blood. In one case a Yaccine of the organism was injected,
apparently with good effect. Milk Diet and Bael and 5-gr. doses of
Ipecacuanha were given with good results in two cases. He thinks the
cases should be regarded as pseudo-sprue, as he has never seen true
sprue recover in Colombo. [This is also the writer's experience in
Calcutta. — L. R.]

G, C. Low'- has studied the role of fungi in sprue, and found them
present in seven out of eight cases, all belonging to the genus Monilia.
He describes a new species isolated from the tongue of one of the
patients. The sugar reactions of the different varieties found are
recorded. They are present in largest numbers in very frothy stools,
and decrease under large doses of sodium bicarbonate, probably owing
to decrease of acidity. Similar fungi are found in other forms of
diarrhoea and in some healthy individuals, so the writer concludes they
are not the cause of the disease.

References. — ^Jour. Trap. Med. and Hyg. 1912, Nov. 337; “Ibid. 1913^
Feb. 33.

SPUTUM. {See also Tuberculosis, Clinical Pathology of.)

Oskar C. Gntner, M.D.

A number of contributions on the subject of the albumin reaction
have appeared duriag the year. The history of the test is given by
Ritter^ and by Ridge and Treadgold.- While the preponderance of
findings is in the direction of the test being significant of tuberculosis.

SPUTUM

54S

MEDICAL ANNUAL

it is important to refer to a paper by Scott,® who points out that a
negative reaction may occur in about 10 per cent of pulmonary tuber-
culosis cases. For this reason it is probable that the practitioner
should regard the test as, at most, of prognostic value rather than useful
for initial diagnosis. Ridge and Treadgold found that albumin disap-
pears from the sputum in cases of pulmonary tuberculosis that have
progressed to complete cure. Continued absence of reaction, associated
with continued absence of bacilli, means absence of active tuberculosis.
Associated with the study of the cells in the fluid, the test becomes
more valuable, because large mononuclear or alveolar cells are present,
indicating the presence or absence of alveolitis in cases of chronic
tuberculosis with emphysema.

Ritter said that a single negative albumin reaction -was certain
evidence that there was no tuberculosis, bat Scott denies this. A posi-
tive reaction is of little value, since it may occur in any of a number of
different diseases of the respiratory^ tract.

Stam for Cells in Sputum (Ridge and Treadgold). — ^A thin smear is
fixed by dipping a slide into i per cent chromic acid for two seconds.
Wash in tap-water, and stain with Unna*s polychrome methylene blue
for three minutes. Rapidly differentiate with 90 per cent alcohol,
wash and dry, and examine with an oil-immersion at once. (Films do
not keep.)

References. — ^Med. Rec., 1913, i, 746; ^Lancet, n, 3S2; ^Jour. Amer.
Med. Assoc.i 1913 i, 440.

SQUINT. {See Ocular Muscles, Disorders of.)

STASIS, PERIPHERAL Herbert French, M.D., F.R.C.P.

Goodharf* points out that there are many patients met with in
general practice to whose malady it is difficult to give a scientific name,
but who present evidence of stasis of the peripheral circulation without
obvious organic disease. Such people have blue hands and feet, they
get chilblains easily, the nose and ears may be red or blue, and associ-
ated with such surface appearances there are all sorts of abnormal
cerebral sensations referable to similar peripheral stasis in the circula-
tion in the brain ; for the lack of a better term he designates the latter

blue brain.'' It is exceedingly common, and there are grouped
around it a number of other conditions of which as yet pathological
knowledge is indefinite ,* Raynaud's disease, angioneurotic oedema,
and Milroy's hereditary trophoedema are probably of the same nature
but more extreme in degree. “ Blue brain is perhaps a mild and
distributed form of Raynaud's disease. It is found in males and
females, adults, boys and girls ; but it is much more common in females
than in males. Cold blue extremities and dead fingers are its most
common symptoms, and paroxysmalism is a usual feature. Amongst
the other protean symptoms are included epistaxis, neuralgic periodic
headaches, migraine, all sorts of feelings in the head, such as a sensation
of weight or of cold, stupidity, woolliness, a far-away feeling, a double,
self, giddiness, dreaminess, depression, tinnitus, deafness, recurrent

NEW TREATMENT

549

STOMACH, CAHCtNOMA OF

fainting attacks without obvious cause. Not a few cases become
regarded as epileptic, and in some there is fear of grave cardiac disorder
when the symptoms take the form of asthma, breathlessness, heart
attacks and arrhythmia, puftiness and dropsy ; and yet the subsequent
course of the case shows that no grave malady was present. Some
cases of acute alarming pulmonary flux are of a similar nature, and so
also are others of rapid swelling of the tongue simulating acute glossitis.
Goodhart remarks that fainting attacks, if recurrent, seldom indicate
heart disease, but much more often peripheral stasis ; though they
cause alarm, the}^ rarely indicate a grave prognosis.

Reference.— 1913, i, 777.

STOMACH, CARCINOMA OP. {See also Stomach and Duodenum,
Surgery of.) Robert Hutchison , M.D., F.R.C.P.

LangwiiR has made a careful statistical study of 200 cases of gastric
carcinoma from the clinic of Professor Caird at the Edinburgh Infirmary,
and concludes that gastric cancer is probably the commonest form of
malignant growth occurring in males. Perhaps, with the exception of
the uterus and breast, it is also the most common form of malignant
growth in females, who are far more frequently affected than text-
books would lead one to imagine. It is not so much a disease of middle
age as one would be led to believe, a marked percentage of cases occur-
ring under forty. The prevalence of the belief that it is a disease of
middle age has often led to disastrous results in the diagnosis of the
disease under forty. Heredity, in some cases, plays an important role
in etiology. When present, it is usually markedly so. All cases of
gastric ulcer, healed or unhealed, are potential carcinomata. {See also
Gastric Ulcer.)

Alcohol, .by acting as an irritant, may cause ulceration and, later,
carcinoma, or it may cause carcinoma directly. Oral sepsis and
carious teeth probablj?- are important factors also. “ Pyloric ’* carci-
nomata are more common than “ gastric.'’ As a rule, the former give
more definite signs. They should accordingly be more easily diagnosed,
and as they lend themselves more readily to excision, operative results
should be brighter.

Gastric disturbance in a person over forty-five should always
arouse suspicion and be considered seriously. Unless definite improve-
ment occurs in three or four weeks under medical treatment, such cases
should be dealt with surgically. Systematic weighing in all gastric
cases should be more commonly practised, carcinoma being marked
by a steady decrease in body-weight. Anaemia being marked in most
cases only towards the close, blood examination is probably useless as
a help to early diagnosis ; subnormal temperature also is probably a
late occurrence. Constipation is a marked feature in practically every
case. Anorexia as a symptom is of the greatest importance — especially
if occurring in a person over forty-five previously healthy — all the
more so if it be accompanied by a feeling of load or weight in the
epigastrium after food, by eructations, water-brash, and heartburn.

STOMACH, CARCINOMA OF

550

MEDICAL ANNUAL

Vomiting and haemorrhage are often too late occurrences to be of value
in diagnosis in the early stages. Pain is an almost invariable early
symptom. Examination of test-meals should be more commonly per-
formed. On the results obtained, however, reliance can be placed
only in the late stages. Earlier, they may support a doubtful diagnosis.
Careful abdominal examination is essential. It must be leisurely
performed and fiequently repeated.

The presence of a tumour above the umbilicus should be a signal
for immediate action, provided the bowels have been cleared out, and
a splenic or hepatic origin excluded. Cases in the past have been sent
to the surgeon much too late — a fact clearly brought out by the rela-
tively small number in which a radical operation was possible.

The only cure at present is surgical, and the mere prolongation of life
is possible only through surgical intervention. All cases of doubtful
gastric disordei, therefore, should be submitted to a careful examina-
tion, first without, and later (if necessary) under a general anaesthetic.
This applies both to chronic cases and to those in persons over forty -fi^’e
with a previousl}^ clean gastric histor^L If, thereafter, doubt exists,
the situation being clearly and definitely described to the patient and
his friends, a surgeon should be consulted. With the surgeon eventually
must the issue lie. Only by the collaboration of physician and surgeon
will an early diagnosis be arrived at, and a consequent radical treatment
be rendered possible.

Reference. — ^Edin. Med. Jour. 1913, i, 222.

STOMACH AND DUODENUM, SUBGERT OF*

Sir Berkeley Moynihan, M.S., F.R.C.S.

Harold Upcott, F.R.C.S.

Ulcer. — Morley^ has constructed a diagram {Fig. 71) showing the
site of perforation in seventy-one cases. There were only two of the
posterior wall, one in the stomach, and one in the first part of the
duodenum. The gastric ulcers are noticeablj^' limited to the region of
the lesser curvature ; of the duodenal, the great majorit}^ were on the
anterior wall close to the pylorus. He reports four interesting cases
in which no gross perforation was found, though general peritonitis was
present. Three of these died, and post-mortem examination failed to
show am- perforation, the base of the ulcer in each case being formed
only by the serous coat.

The table showing the relation of mortalih^ to the time between
perforation and operation speaks for itself.

j 0 to 12 hrs.

12 CO 24 hrs.

24 to 36 hrs.

36 to 4S hrs.

Lived . . ; 36

6 1

Died . . j 2

1 i

1 5

Turner^ thinks there are two types of duodenal ulcer ; perforation
is an accident almost peculiar to one type, while it is an accidental
complication of the other. He does not believe it possible to tell when

NEW TREATMENT

531

STOMACH AND DUODENUM

perforation is imminent. After a period of pain and shock there is a
period of reaction, in which it may not be eas}' to realize that perfora-
tion has occurred ; on this account, the history of the initial attack is
of great importance.

The pros and cons of primary gasfyo-eyd^yiX'tomy find a place in all
discussions of this subject. Turner points out that in favour of primart’
gastro-enterostomy is the fact that “ kissing ulcers ” are not uncom-
mon ; an acute perforating ulcer on the anterior wall may be secondary
to a chronic ulcer on the posterior wall, and suture of the former

will not cure the latter. Corner^ estimates
that about one-third of the cases are cured
by suture onl3", and that in these a gastro-
enterostomy done at the primary operation
would have been unnecessary. At the
same time he admits that many subjects
of the perforation of a gastric ulcer are
benefited b}- a gastro-enterostomy. This
is especially true if the perforating ulcer
is in the neighbourhood of the p3dorus.

He concludes that, as a rule, a second-
ary gastro-enterostomy, done when it is
needed, is better than gastro-enterostomy
done at the original
operation, which
may after all not be
required. He points
out that it is com-
mon for patients to
have an attack of
pain and dyspepsia,
commencing a few
months
o p e r a ti

closure of the per-
foration, which is
general!}’ cured completely by medical treatment ; the latter should
therefore be applied to anticipate such symptoms in eveiy" case of
recoveiy from perforation of a gastric ulcer.

It is well known that the oedema and friability of the tissues around
a perforated ulcer often make its suture a matter of difficulty. Comer
has shown that in such cases the perforation may be successfully
tamponed and isolated with omentum or gauze ; and he again draws
attention to this method of treatment, which he holds should be adopted
in all cases where suturing presents any difficulty. Neumann* gives
his further experiences in the use of an omental cuff in the treatment
of perforated ulcers of stomach and duodenum. His method consists
in passing one end of a rubber tube through the perforation into the
stomach or duodenum, and bringing the other end through the incision.

after the
on for

# = rerforar:o.i on Anfenor Surface
© = Perforation on Posterior Surface

-Diacjrum >hov.ir.g ■^ite of perforation of gastric and
duodenal ulcers in jt casess.

STOMACH AND DUODENUM

552

MEDICAL ANNUAL

The intra^abdominal portion of the tube, which serves the double
purpose of draining the stomach and providing a means, for early
feeding of the patient, is wrapped round wdth omentum.

He recommends this method specially in cases where the perforation
is so near the pylorus that suture would cause obstruction ; but the
technique is so simple, and the after-course so smooth and safe, that he
thinks its use should be extended to other cases.

Cancer, — W. J. Mayo® gives the experience gained from 1000 opera-
tions for carcinoma of stomach, of which 378 were resections,. 246
were palliative operations, and 376 explorations.

The results of surgical treatment of gastric cancer compare favour-
ably with the treatment of cancer in any other organ of the body, but
it is most important that it should be carried out early. A clinical
diagnosis of cancer of stomach cannot often be made early enough to
obtain a radical cure by operation ; but, as his figures show, in over
one-third of the cases it was possible to make a diagnosis of some
surgical condition, probably cancer, sufficiently early to permit resec-
tion of the growth. The aim of the diagnostician should be to suspect
cancer rather than wait for a positive diagnosis. A suspicion of cancer
is aroused by the presence of a palpable tumour, by evidences of food
retention in the stomach (these two signs combined are pathognomonic
of cancer in a case otherwise suspicious), by the deformities and muscu-
lar deficiencies shoum by the A-'-rays, and by an examination of the
gastric contents, A suspicion of cancer is enough to justify early
operation, which should always be commenced as an exploration.

According to Mayo, a patient submitted to exploration with a prob-
able diagnosis of cancer of the stomach, has a little over one chance in
three that the operation will be radical, a little less than one chance in
three that it will be palliative, and about one chance in three that it
will be merely exploratory. The mortality among the 376 explora-
tions, in which nothing further was done, was i*6 per cent. If on
exploration a resection is deemed possible, the portion of the stomach
containing the tumour is drawm out of the wound for further inspection.
It may be difficult to decide on a course of action when the stomach is
mechanically removable, but enlarged and possibly infected l3?Tnph nodes
are found which are not removable. Mayo thinks that if such patients
are in fair condition, and the operation presents no special difficult^",
resection is justified, since it will probably give one or two years of
comfortable existence. Palliative operations should not be performed
except for the relief of mechanical obstruction, or when there is doubt
as to whether the condition is due to ulcer or cancer. Gastrostomy
may be required in the presence of cancer obstructing the cardiac end
of the stomach, and jejunostomy is also occasionally of value.

AltsehuH reports the results in 257 cases from Wolfler*s clinic.
Gastro-enterostomy was done in 195, wdth a mortality of 28 per cent,
the average duration of life after operation being seven and three-
quarter months. Resection was done 64 times, with a mortality of
40 per cent. Most of these deaths were from pulmonary complications.

NEW TREATMENT

553

STOMACH AND DUODENUM

Of the 38 patients who recovered from operation, 3 died later from
other diseases without recurrence ; 5 have remained cured for over
five 3'ears. In the remainder, recurrence has taken place more or
less rapidly, the average length after operation being thirteen months.

An Important study of 157 Resections performed in Kuttner’s
clinic is that of Weil.'^ In the last five and a half years over 900
patients were treated for gastric affections in this clinic, with about
800 operations. Of these, 149 were t^^pical gastric resections, 14
of them being done for callous ulcer, simple excision of which was not
suitable treatment.

Resection was practised in such cases, only because it could not be
decided whether the trouble was benign or malignant, and Weil empha-
sizes the fact that in a great number of cases one is not in a position to
distinguish between them. There were 5 cases which seemed at the
operation to be benign ; but, doubting his ability to differentiate,
Kuttner practised resection ; histologically they proved to be carci-
noma.

Among these 14 patients there were 3 deaths — i from pneumonia,
I from gangrene of lung, and i from haemorrhage from further gastric
ulceration ; a proof that resection does not always protect against this
misfortune.

Of the 135 resections for cancer of the stomach, two-thirds were in
men ; over 50 per cent of the patients were under fifty. According to
the duration of symptoms, the cases may be divided into two groups.
In the larger, the trouble has existed only a short time, a few months,
or at most one to two years. In a smaller group — about 25 per cent
of the cases — the gastric symptoms were of several years’ duration,
from which one may conjecture that the cancer had developed upon
an old-standing ulcer or hyperacidity. In by far the greater number,
gastric pain was complained of ; in only 10 per cent had the trouble
developed painlessly. Vomiting was absent in only 20 per cent.
Wasting was almost constant. In four-fifths of the resected cases,
there was a palpable tumour or definite resistance in the upper abdomen.
Weil stoutly combats the prevalent view that where there is a palpable
tumour the radical operation will be impossible. On the contrary, the
pyloric tumour which can be felt offers a good chance of resection.

The opposite view — that radical operation should only be performed
in the presence of a palpable and mobile tumour — is also not to be
relied upon. Resection was done in numerous cases where there -was
merely a doubtful resistance — generally a sign of growth of the lesser
curvature. Weil does not think the A^-rays are of much value in decid-
ing as to the operability of cases ; he has never seen an early diagnosis
of gastric cancer made thus.

The resections were for the most part difficult operations ; only in
one-third was it noted that the procedure was relatively simple. The
difficulty was due to the fact that in about 20 per cent, the tumour was
adherent to Hver and pancreas ; and in about three-quarters of the cases
there was extensive glandular involvement. One resection is to be

STOWACH AND DUODENUM

554

MEDICAL ANNUAL

reckoned as an almost total gastrectomy. Five times the colon was
invaded by the growth, and had to be removed with the stomach ;
three of these died ; one is alive and well one yeax after operation, and
the other was well for two years, then had recurrence which led to
common duct obstruction. In three cases, the operation was done in
two stages, the first being a gastro-enterostoniy. One patient remained
well four years. In the second the result is equally good ; while in
the third, three 'sveeks after the first operation, unexpected difficulties
were found, due to the unusual increase in the size of the tumour.

The method of treating inoperable carcinoma of the stomach b}- the
X-rays as employed by Czerny, has been elaborated by Finsterer® in
the following manner. The abdomen is opened under local anaesthesia,
and gastro-enterostomy performed if possible. The recti are then
divided transverseh^ three fingers’ breadth abo\’e the umbilicus.
Gauze is packed under the edges of the incision, which is left open,
forming a rhomboidal space in which the anterior surface of the stomach
is freely exposed and may be treated by irradiation. He has thus
treated 7 cases. 4 were much improved. 3 patients are dead, i from
bronchopneumonia, while the other 2 had extensive liver metastasis.
None of the patients developed peritonitis, or a hernia through the
large wound.

Gastrostomy. — Ropke® thinks that the usual methods of forming an
oblique or tortuous canal fail, b}’ reason of traction which changes them
into direct and leaky fistulse. He reports a case of cancer of the oeso-
phagus in which he performed gastrostomy by the following method :
The omentum was separated from the greater curvature of the stomach
as far as the pylorus. A quilted suture was then passed through both
walls of the stomach along a line parallel to, and two fingers’ breadth
from, the greater curvature. A strip of stomach below this suture was
then cut away, beginning at the pylorus and extending to the fundus,
where the strip was left attached. The quilted suture was buried by
inverting the cut edges of the stomach, and by continuing tliis inverting
suture on to the strip of stomach, the latter was converted into a
small tube. This tube — in Ropke’s case 22 cm. long — ^was drawm up
through a tunnel under the pectoral muscle toward the left clavicle,
and its open end was sutured to a small opening in the skin. The
abdominal wound w’as then closed completely, the patient being fed by
this tube eight days later. No leakage occurred. [An operation of
this complexity is unsuited to the palliative treatment of oesophageal
cancer. A further drawback is the delay in feeding bv the new route.
— B. G. A. M., H. U.]

J'olv'nlus of Stomach. — Kerr^o defines idiopathic volvulus of the
stomach, as a rotation of the organ around the axis of the lesser curva-
ture occurring apart from any other pathological condition.

The stomach turns through an arc of 180 degrees from left to right
and from behind forwards, so that the greater curvature comes to lie
above, under the left lobe of the liver and diaphragm, while the lesser
curvature is below. The posterior surface lies under the anterior

NEW TREATMENT

555

STOMACH AND DUODENUM

abdominal wall, separated from it by the great omentum. None of
the reported cases showed any degree of strangulation. The lumen of
the pylorus is obliterated by the rotation before that of the cai'dia,
thus increasing the gastric distention. The transverse colon usually
lies abo\-e the stomach, and is obstructed by the distention of the
latter. (In Kerr’s case the gastro-colic omentum was ruptured, and
the colon lay below the stomach.)

The cause of this rotation is problematical, but Kerr thinks it is due
to lack of splanchnic control, associated with laxity or rupture of the
stomach ligaments The usual symptoms are a sudden onset of pain
and distention, ^"olrliting may occur at first, but then ceases when
the cardia is occluded, while the distention increases. The stomach
tube cannot be passed. The upper abdomen is greatly distended, while
the lower part remains flat. Immediate opei'ative treatment is indi-
cated. The stomach should be aspirated, and then replaced in its
normal position.

Intussusception of Stomach and Duodenum. — ^\Vade^^ reports an
interesting case of a pedunculated fibromyoina of the stomach which
had passed through the pylorus and duodenum into the jejunum,
dragging after it the stomach wall and producing air intussusception.

The patient had suffered for some time from gastric crises due to
partial invagination of the stomach, and from attacks of slight jaundice,
probably caused by pressure of the tumour of the iiitussusceptum on
the orifice of the common duct. Probably these attacks terminated
by natural reduction of the intussusception. During the last two days
the symptoms were those of total obstruction. At operation, the
invagination was reduced, and the pedunculated tumour excised with
the portion of stomach wall from which it arose.

Hour-glass Stomach. — The possibility of congenital hour-glass
stomach is admitted by Tuffler and Roux-Berger,^- but they think
that it is very rare. By far the most frequent form of hour-glass
stomach is that caused by callus ulcer of the lesser curvature. The
stricture is generally nearer to the pylorus than the cardia, and in the
cardiac pouch there is stasis of food — an important point in the diag-
nosis between true, and false or spasmodic biloculation, which closely
resemble each other on radiographic examination. The symptoms
are those of pyloric obstruction. The ,r-rays afford the greatest help
in diagnosis.

The authors regard annular gastrectomy (resection of the stricture),
with anastomosis of the two halves of the stomach, as the best treat-
ment. This may be undesirable in certain cases, e.g., when the
patient is not in a condition to stand so severe an operation, in the
presence of extensive adhesions, when the constriction is high up
towards the cardia, or when it is complicated by pyloric stenosis.
In these cases gastro-enterostom3^ is indicated.

Acute Dilatation of Stomach. — ^According to Borchgre\dnk,^^ the
symptoms are vomiting, abdominal distention, and collapse ; together
with pain and tenderness over the swollen stomach, great thirst, and

STOMACH AND DUODENUM

556

MEDICAL ANNUAL

scanty urine. The vomiting is frequently repeated at short intervals.
Distention is usually greatest on the left side. Gradually, the patient's
strength fails and the pulse-rate increases. Sudden collapse may
occur, and in many cases this is the first recognized signal of the illness.
From a study of the literature, and from his own experience, he urges
the value of the Prone Position. In 22 out of 26 cases this proved
curative, and in most of them the immediate relief when this simple
change of position was adopted was most striking.

References. — '^Pvact. 1913, i, 907; ^Med. Press and Circ. 1912, h, 230;
^Lancet, 19x3, i, 600; *DeuL med. Woch. 1913, 554; ^Jour. Anier, Med,
Assoc, 1913, ii, 540; ^Beiir, z. klin, Chir, 1913, 421 ; ’^Berl. klin. Woch, 1913.
390; ^Munch, med. Woch. 1913. 855; ^Zentralbl. f. Chir. 1912. 1539; '^K 4 nn,
Siirg. 1912^ ii, 697 ; ^^Surg. Gyn. and Obst. 1913, ii, 1S4; ^“Presse M^d. 1913,
369 ; ^^Sxivg. Gyn. and Obst. 1913, i 662.

STOMACH, DILATATION OF. {See Operations, Complications fol-
lowing.)

STOMACH, FIBROMATOSIS OP. Robert Hutchison, M.D., F.R.C.P.

This condition is also kno’v^m as linitis plastica " and as “ cirrhosis
of the stomach,” and a paper by Lyle dealing with it under the latter
title was summarized in the last volume of the Annual. Alexis
Thomson and Graham^ have recently published another careful study
of the condition, using the term “ fibromatosis " to describe it, and
their conclusions on the whole agree with those of Lyle already referred
to. They believe that they are in a position to clear up the long-
standing controversy as to whether the condition is simple or malignant.
They have found that it is usually simple, but that there occurs a diSuse
infiltrating form of scirrhous cancer which, in its distribution, resembles
fibromatosis, and can only be distinguished from it by careful and
prolonged microscopical examination. They have no faith in the
results of the ” rapid ” examination of sections prepared whilst an
operation for the disease is in progress. They have always found
the fibromatosis to be associated with the presence of an ulcer (which,
however, may have become malignant), and therefore consider that
the condition might more fitly be termed ” ulcer-fibromatosis.”

Two chief forms may be distinguished : (i) Localized, which starts
at the pylorus and spreads along the lesser curvature ; (2) Diffuse —
so-called ” leather-bottle stomach.” This variety the authors are
inclined to suspect is always malignant; but they admit that further
observations on the subject are required before this view can be defi-
nitely accepted. Their paper contains a minute account of the naked-
eye and microscopic characters of gastric fibromatosis, and is profusely
illustrated.

Reference. — ^Edin. Med. Jour. 1913, ii, 7.

STRABISMUS. A. Hugh Thompson, M.D,

A new operation for squint is practised and described by Bishop
Harman,^ the main practical advantage of which is that it does not
necessitate the patient’s being kept in bed, or the bandaging of both

Iv’EW TREATMENT

557

STRABISMUS

eyes, and can therefore be performed in the out-patient department.
The same can be said of an ordinary tenotomy ; but the very unsatisfac-
tory results which commonly follow from this operation, and the
frequency with which secondary divergence is seen in those who have
had tenotomy performed in childhood, has caused ophthalmic surgeons
very generally to abandon it in favour of the advancement of the anta-
gonist. Harman’s operation is a Subconjunctival Advancement by
means of a special reefing forceps and sutures, the opposing surfaces
of the tendon ha\Hing been previously scraped hy a special tendon rasp.
For a description of these instru-
ments, and of the whole operation,
the reader is referred to the original
papers. One point which applies
not only to his own, but to all
operations for advancement, ma}^ be
given here. The suture inserted
into the sclera should lie parallel to
the corneal limbus, and not at right
angles to it. By the former method
the tension on the suture is decidedly
less than by the latter. The reason
why the parallel suture is not more
generally employed is probably the
difficulty in fixing the globe while
the suture is being inserted. Harman
overcomes this hy a special tempor-
ary suture by which the globe can
be held firmly. A more convenient
method is to use a special fork de- y^.-Rasner Batten's riN-ati,.™
vised by Rayner Batten. ^ Fig. 72

shows the fork inserted into the sclera, fixing it so that the operator
can pass the needle through the required amount without difficulty.

Although, as has been said, the old operation of tenotomy ought to
be abandoned, according to the best opinions, this does not appW to
operations for Partial Tenotomy, by which, in cases where it may be
necessary, the effect of an advancement may be increased. This is

73 -

best performed by Harman’s method,^ He makes three separate
parallel cuts, each part way only through the tendon, the two outer
ones going exactly half-way through, the middle one three-quarters
through. The result is to lengthen the tendon without dividing it.
The two diagrams {Fig. 73) show this: b is the capital cut \ a, a' the
two lateral ones, and c the axis of the tendon. The left hand

STRABISMUS

558

3MKDICAL ANNUAL

diagram shows the original shape of the tendon, the right hand one the
alteration caused by the cuts. In order to facilitate the middle cut,
Hannan has devised a special director- forceps^ 74), the lower

blade of which has a longitudinal groove on its inner surface, while
the upper one has a corresponding slot, and a transverse mark at the

Fig^ 74* — Harman’s Director-forceps.

middle point. The middle cut is made by running a knife along the
groove to the required point, the lateral cuts at each side of the forceps
by scissors.

Perhaps on no point does the practice of different ophthalmic surgeons
vary so widely as in Ppescription of Prisms. Some statistics of definite
results collected by Reber are therefore worth quoting.'’’’ In 1008 cases
in his practice, symptoms traceable to defective muscular equilibrium,
not cured by correcting the refractive error, were in evidence. Of
these, 602 were cases of exophoria. In rgo of them prisms were ordered
(base outwards) for exercise only. In 130 of these (68 per cent) the
result was good. In the remaining 412, prisms (base in) were incorpo-
rated ill the patients’ glasses either for constant use or for reading only.
In 328 of these (79 per cent) the result was good. Thex*e were only 5(>
cases of esophoria causing symptoms. In half of these, exercising
prisms were ordered (base in), and the result was good in 50 per cent
only, in the other half, prisms (base out) were prescribed for constant
wear, and the result was good in 24 out of 28 (85 per cent). Lateral
errors never cause symptoms in anything like the same proportion of
cases as do vertical errors, and the number of times that hyperphoria —
itself a much less common condition than exo- or esophoria. — needed
correction was 350. In 14 cases, exercising prisms weie tried, but in
only one case was the result good. On the other hand, vertical prisms
Avere incorporated in the patients’ glasses 336 times, and the result
was good in 297 cases (88 per cent), the highest percentage of good
results of any. These, according to the reviewer’s experience also,
are by far the most satisfactory cases in which to order prisms.

References. — '^Trans. Ophth. Soc. 1912, 2^6; and Ophthalmoscope, 1912,
72S ; '■^Trans. Ophth. Soc. 1912, 132; ^Ophthalmoscope, 1913, 18; ‘Hbid. 24;

Ophthalmol. 1913, 457.

SUGGESTION IN THERAPEUTICS: ITS LEGITIMATE USES.

Piirves Stewart, M,D., F.R.C.P,

The bulk of English physicians at the present time appear to have
relatively less enthusiasm than their colleagues abroad for this form
of treatment, although we must not forget that it is largely upon the
observations of Elliotson of University College, London, in 1838, of

NEW TREATMENT

559

SUGGESTION

Braid of Manchester, in 1841, and of Esdaile, an English physician in
Calcutta, in 1845, that modern h3rpnotism is based.

This is not the occasion for a historical or bibliographical study of
psycho-therapeutics. I prefer to limit myself to a brief account of the
fundamental data, as at present conceived, of suggesti’s'e therapeutics,
and to indicate some of the more important indications and contra-
indications for its emplo^T-ment. For much of the material of this
article I am indebted to the works of Forel,^ Moll,^ Tuckey,^ Bramwell,^
Crichton Miller,® and others, which I have freely utilized.

It has been well said that successful medical practice without the
employment of suggestion is impossible. There is always the influence
unconsciously exercised by the mind of the physician upon that of his
patient, varying with the personality of both. But, in addition, we
may sometimes deem it advisable specially, and it may be exclusively,
-to lay stress upon psycho-therapeutics. For this purpose various
methods may be employed. Before describing them, a few preliminary
hints may be offered to the practitioner who proposes to obtain thera-
peutic results by such means.

Firstly, an accurate diagnosis of the case must be made, and adequate
grounds must be present to call for the employment of suggestive
therapeutics. . Sometimes, it is true, as Forel has pointed out, the
phenomena of hypnosis may actually be used for aiding in the process
of diagnosis, but such cases are exceptional. The hypnotic operator
requires patience, enthusiasm, and a confident, unhesitating, but not
aggressive, manner : — qualities which are not found in every medical
practitioner, however skilled he may be in other respects.

The person who is to be hypnotized should be approached frankly
and naturally. It should be explained to him that there is nothing
unnatural or uncanny about the procedure, but that it is a character-
istic of the nervous system which applies to everybody. He is told
that he will be readily influenced or fall to sleep ” (Forel). This, it
will be observed, is already the first stage of suggestion. Some opera-
tors at the first seance are content with gaining the patient’s confidence
and overcoming any prejudice which he may have against hypnotism,
no special effort being made to induce hypnosis. In some cliniques,
e.g., that of Liebault, Wetterstrand, and others, the patient, on paying
his first visit, is directed to sit down and to watch the hypnotic treat-
ment being applied to others. This gives him confidence, and also
arouses his imitative faculties. In most cases, however, we have only
a single patient to deal with at a time.

He is placed in a comfortable easy-chair, with or without arms.
The chair may be so placed that one side touches the wall of the room,
so that, later, the operator can assist a suggested catalepsy of the
patient’s arm, if he is not quite certain of success, by leaning the limb
against the wall (Forel). The patient must not be in a state of excite-
ment, anxiety, or expectant tension. This last condition is what
spoils the first attempt at hypnosis in a large number of patients, who
imagine and expect all sorts of weird and wonderful phenomena.

SUGGESTION 560 MEDICAL ANNUAL

Other patients are unwilling subjects, or are afraid they cannot be
hypnotized, and in consequence they produce in themselves an auto-
suggestion of an antagonistic nature, which is often very difficult to
overcome.

The patient takes his place in the armchair. He is told to relax his
muscles, and to try and make his mind a perfect blank, to think of
nothing at all. Complete silence must be obtained. He is then asked
to fix his eyes and his attention on some visible object — ^the operator’s
eyes, or hand, or a small glittering metal object held above the level
of the eyes, and close enough to necessitate an effort of convergence,
thereby tiring the ocular muscles. After about a minute of this
staring on the part of the patient, the operator begins his verbal sugges-
tions in a firm, loud, and monotonous voice. He suggests the onset
of natural sleep thus ; " Your eyes are becoming moist ; they are quite
moist. Your sight is growing dim and misty. Your eyelids are
becoming heavy ; they are very heavy. Your limbs are becoming
pleasantly warm, and a numbness is creeping over your arms and legs.
Your arms are becoming as heavy as lead.*' (Meanwhile the operator
raises the patient’s hands by the wrists and makes them fall with a
slight push). " My voice is becoming muffled. You are feeling
more and more sleepy. Your eyelids are so heavy that you cannot
keep them open.” (Meanwhile he slightly depresses the object at
which the patient is gazing, so that the patient’s lids follow the eye-
balls downwards ; if the eyelids close spontaneously, so much the
better ; if not, the operator gently closes them.) '

The effect of the foregoing procedures varies in different patients ;
some merely feel a slight torpor with disinclination to open the eyes ;
others will fall into a deeper sleep, during which the further stages of
catalepsy, somnambulism, etc,, can be suggested. These deeper states
of hypnosis have been divided by some observers into various definite
stages, but such dividing lines are quite artificial.

Once the patient is in the ” first stage ” of lethargy, the operator
lifts up an arm. into a certain position, e.g., against the wall or against
the patient’s own head, meanwhile suggesting that the limb is rigid,
and that it will be irresistibly drawn against the wall or head, as if by
a magnet, so that it is impossible for the patient to put it down. In a
successful case the limb remains rigid in the suggested position. It
should be remembered that the patient is completely conscious all the
time, and that he both hears and remembers everything said to him by
the operator, and can reply to him. If the patient tries to depress his
arm, the operator quickly prevents him, and continues to suggest
somewhat as follows : '‘You see you are getting sounder and sounder
asleep. Your arm is growing more and more rigid. Now you cannot
depress it.” In critical and refractory cases it is wise to avoid the
suggestion of catalepsy of the arm at the first seance. In deeper
degrees of hypnosis the patient becomes increasingly drowsy, though
still able to hear every word addressed to him. In Liebaiilt’s ” third ”
degree, a movement communicated to a limb is continued automatically

NEW TREATMENT

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561

by the patient, e.g., if the forearm be alternately pronated and supi-
nated, it will go on doing so, until the operator directs it to stop. In
the so-called fourth “ degree the patient only hears what is said to#
him by the operator ; to all other stimuli he is insensitive.

During the stage of catalepsy the operator may suggest the occur-
rence of anaesthesia of one or more parts of the body, or the disappear-
ance of pain from a part previously painful, meanwhile touching the
painful part, and declaring at the same time that the pain is disappear-
ing. The operator asks the patient as to the result, and in many cases
the patient admits that the pain is relieved. After the deepest
degrees of hypnosis — so-called somnambulism — the patient has no
subsequent recollection of w^hat he has done during the hypnotic state.
In order to wake the patient, it is enough to suggest that he should
w^ake up at once, accompanying the suggestion, perhaps, by blowing
lightly on his e3’-es. Before allowing the patient to wake up, the opera-
tor should suggest to him that he will feel no disagreeable after-e:ffects
on waking ; but that, on the contrary, he will feel fresh and normal
in every respect.

Innumerable modifications of the above procedures are employed.
Every operator discovers for himself minor variations of suggestive
methods, which he has found by experience to be specially suitable
to his own personality, and therefore efficacious. Thus Woods ^
discards external objects on which to fix the patient's eyes, and com-
mences by placing one hand on the epigastrium and with the other
gently stroking the head, face, or arms. Additional help may also be
obtained by means of static electricity, as described by Ash,® who
places the patient’s chair on an insulated platform, and applies a gentle
static breeze to the head. The effect of this is remarkably soothing,
and enables the patient to relax himself more completely, both physi-
cally and mentally. He is then in a better condition to receive sugges-
tions from the operator, or to give himself such self-suggestions as may
be desirable.

In most cases it is unnecessary to send the patient actually to
sleep. Suggestions can almost always be made with equal efficacy
wdth the patient a^vake. Some patients who cannot be, or are unwill-
ing to be, hypnotized, are nevertheless highly susceptible to waking
suggestions. The patient is placed in a comfortable chair in a quiet
room, and is made to relax his muscles to the utmost. After a period
of silence, perhaps accompanied by gentle epigastric pressure with
one hand and soft stroking of the head and face with the other hand,
the suggestions are then uttered by the operator, quietly,. deliberately
and, above all, confidently. Woods advises those who are beginning
the practical study of suggestion to commence by producing the
hypnotic sleep, since w^aking susceptibility is best marked in patients
who have previously been put to sleep once or twice before. Never-
theless, once the operator has acquired confidence and experience, it
is often possible to produce marked response to suggestion in the
waking condition, even in patients who have never been hypnotized

3 ^

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before. Tims the operator lifts the patient’s arm, and says, “ Now
\^on cannot move it.” In a successful case the limb remains in a
condition of cataleptic rigidity. Apart from producing gross physical
phenomena such as these, the operator can suggest that a patient’s
i:>ains are disappearing, that he is losing various phobiae or feelings of
apprehension, that tics or habit-spasms, abnormal cravings, etc., are
passing away, and so on.

The term Auto-suggestion is used when the ideas are suggested by the
patient to himself, and not, directly at least, by an outside operator.
lit some cases an individual may be able to induce actual sleep by auto-
suggestion. The monk of Mount Athos is said to induce an ecstatic
trance in himself by gazing at his own umbilicus. To take more
homely examples, we are all familiar with the drowsy effect of gazing
at a glowing red fire. Constantly-repeated, regular, monotonous,
auditory stimuli, not too violent, such as the ticking of a clock or the
distant breaking of waves on a seashore, may also induce sleep. The
mere habit of going to bed and of assuming a particular position each
night, at a particular hour, induces sleep in most people, altogether
independently of the existence of special physical fatigue during the
preceding day.

Apart, however, from the hypnotic sleep, auto-suggestion may
induce innumerable other symptoms. Hypochondriasis is the effect
of morbid introspection, together with exaggeration of minor discom-
forts by auto-suggestion. Hysterical paralyses, contractures, and
anaesthesiee are also probably the result of auto-suggestion, sometimes
induced in the first instance by a local stimulus or injury, directing
the patient’s attention to the afflicted part.

But patients may also be taught to employ auto-suggestion curatively
for the relief of various symptoms (e.g., pain, vertigo, insomnia, func-
tional paralysis, etc.), provided always that no serious organic hindrance
be already present. The curative action of certain ” holy springs,”
such as that of Lourdes, depends for its success upon the faith or auto-
suggestion of the sufferer and upon the absence of gross organic disease.
The same remark applies to the occasional cures wrought by ” Christian
.Science,” with its perpetual reiteration of incoherent, but, on the
w'hole, reassuring sentences, its denial of the existence of pain or disease
(and even of death !), combined with a shrewd system of pecuniary
depletion.

Persuasion is a method of treatment which has been specially elabor-
ated by Dubois,^ of Berne, who discards the ordinary methods of
suggestion, whether in the hypnotic or in the waking state. His aim
is to instruct the patient by explaining to him that it is his own mind
which, by morbid introspection and excessive attention to disagreeable
symptoms, has been maintaining or aggravating these symptoms. He
is told that his own intelligence and will-power have to be brought
into play. Duboi’s method, appealing directly to the patient’s reason,
differs fundamentally from ordinary suggestion, where the patient’s
reasoning faculties are either evaded or deliberately put out of action.

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SUGGESTION

Psycho-analysis. — Freud, Breuer, and their disciples have elabor-
ated a theory of hysteria according to which all hysterical S3rmptoms
are the result of some psychical trauma of a sexual nature. The term
sexual " is here used so as to include not only the familiar gross
sensory and emotional experiences connected with the reproductive
organs, but also other groups of emotions, such as family aifection,
outside the ordinary meaning of the word. According to Freud, this
intense emotional experience, constituting the sexual trauma, only
produces hysteria when it is '' repressed/" i.e. when it is denied its
normal reaction or expression, e.g., of anger, of joyful satisfaction, etc.
The emotion, by an effort of will, is prevented from dominating the
patient’s attention at the time, and is consequently bottled up or sub-
merged ; and the individual acquires the habit of keeping the incident
out of his consciousness. As a matter of fact, he may apparently forget
it altogether. Nevertheless, this sexual trauma, not finding its normal
outlet at the time, continues to attract the patient’s attention, and a
continuous effort must be made to keep the attention off it. This effort
wears out the powers of control and, finally, control being lost, the idea
is supposed to gain expression in an abnormal manner by producing
various hysterical phenomena. To cure the hysteria, Freud tries to dig
up the buried memory of the old trauma by a process of cross-examina-
tion termed psycho-analysis,*’ and he claims that when it is at last
brought to the surface of the patient’s consciousness and, as it were, ven-
tilated, this emotional purgation ” dissipates the hysterical symptoms.

The methods of psycho-analysis are threefold : (i) In free association
the patient rests quietly in an easy chair, whilst the operator sits behind,
or at least out of sight, and by skilful cross-examination tries to lead
the patient’s memory back to the original circumstances tinder which
his hysterical phenomena first arose, following up one clue after another.
The patient meantime tries to make his mind a receptive blank, and
frankly answers all the enquiries made by the operator until he succeeds
in giving a detailed account of the original experience which produced
the hysterical symptoms. The process is slow and tedious, and
numerous seances are often required to track the hysteria to its sexual
lair. (2) In dream analysis the patient is encouraged to remember
his dreams, no matter how fantastic, and to relate them in detail to the
analyst,” in the hope that the idea therein contained may offer a clue
as to the original sexual trauma. Hypnotic suggestion is often used
as an accessory, and the patient is told to dream of something connected
with his illness. (3) Time association is based on the fact that the
mind normally has the power of instantly tacking one idea on to
another. The analyst reads out a selected list of utterly dissociated
words, one at a time, and at each word the patient is asked to give
the associated word which he thinks of in return. Thus, for example,
the word ” egg ” may suggest the response ” spoon ” in one patient,
whilst in another it may suggest the word chicken,” and so on. In
any case, a word of some sort is given by the patient as a response to
each test-word in turn. The analyst goes through the list, and with

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MEDICAL ANNUAL

the aid of a vstop-watch records the number of fractions of a second
required in each case for the associated word to be forthcoming from
tile patient. If a word on the analyst's list is followed by an abnormal
hesitation on the part of the patient, this suggests that the submerged
trauma is in some way involved. Moreover, the patient sometimes
gives the same word again and again in response to different test-
words, and this recurrent I'esponse is supposed to be useful in guiding
tlie analyst as to the original sexual trauma.

Indications and Contraindications for Treatment by Sugges-
tion. — Before sanctioning the employment of hypnotism or any other
form of psycho-therapeutics, we must make an accurate diagnosis, since
diseases which are due to gross physical or anatomical lesions are unsuit-
able for treatment by suggestion. It will be universally admitted,
for example, that in a patient with a mammary cancer, an attack of
pneumonia, or a transverse lesion of the spinal cord, treatment by
suggestion would be not merely foolish but criminal. Not only organic
nervous diseases, but certain other nervous maladies, such as epilepsy,
paralysis agitans, etc., in which no constant morbid changes have yet
been demonstrated, are also unsuitable. Certain psycho-therapeutic
physicians claim, wdth apparent sincerity, to have beneficially influenced
the tremors of paralysis agitans and the lightning-pains of tabes
dorsalis ; but the careful reader cannot help regarding such statements
with scepticism, and wondering whether the pains thus relieved were
really tabetic in origin, and whether the tremors were those of paralysis
agitans. On the other hand, it is extremely common to meet with
combinations of organic and functional disease in the same patient,
and there is no reason w'hy a tabetic individual should not suffer also
from hysterical pains, which may be treated with success by suggestion.

Epilepsy is as a rule intractable to suggestion. There is, nevertheless,
a certain type in which an exception may be made, viz., that form in
which there is a deliberate and slow aura. In some of these cases the
patient may, by an effort of will, fight against his aura, and thus inhibit
his threatened fit. In such a patient suggestion may be usefully
employed to increase the will-power ; but suitable cases of this sort
are numerically few. Epileptic patients are often specially easy to
hypnotise, but this fact does not have any beneficial effect on their
epilepsy, save in the exceptional cases above mentioned.

Mental diseases are generally unsuitable, partly owing to the diffi-
culty of hypnotizing such patients. The beneficial effects of asylum
environment are partly suggestive in effect ; and Woods claims to have
hypnotized successfully a certain proportion of insane patients ; but
other observers, like Tuckey, equally skilled, frankly admit that in
mental diseases they have failed to produce the slightest hypnotic
influence. The psychoses dependent on hysteria and on alcoholism
are probably those which are most likely to show positive results.

Of all the neuroses, hysteria is the most suitable for treatment by
suggestion. In fact, one definition of hysteria, by Babinski, limits
the disorder to such symptoms as are produced by suggestion (whether

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SUGOESTION

by auto-suggestion or by suggestion from outside), and therefore
removable by the same means. If, on the other hand, we agree with
Freud's theory of hysteria, psycho-analysis is indicated. AVhether or
not -we accept either of these definitions, it is beyond doubt that hysteria
is par excellence the malady in which suggestive therapeutics have
gained their most striking triumphs. Paralytic phenomena, w'hether
sensory (as in anaesthesia) or motor (as in catalepsy, astasia-abasia,
aphonia, mutism) often yield to suggestion with dramatic rapidity.
Subjective hysterical symptoms of an irritative nature, e.g., hysterical
pains, hysterical tinnitus, or pruritus, can also be attacked, after careful
exclusion of all organic causes capable of inducing the symptoms.
Hysterical convulsions and spasms are also suitable for treatment by
suggestion, although, as a rule, they are less rapidly influenced, owing
to the fact that during a paroxysm it is more difficult for the operator
to secure the patient’s attention. It is often advisable to employ
some counter-stimulus, preferably of a disagreeable kind, e.g., painful
pressure over the supra-orbital nerves or in the iliac fossae, to divert
the patient’s attention from her active paroxysm. Once this is done,
the hysterical fit usually subsides, and we can employ suitable sugges-
tion to prevent its recurrence.

Pyschasthenia, with its characteristic phobiae, obsessions, and habit-
spasms, is also beneficially influenced by therapeutic suggestions.
Here, however, the patient is often more difficult to influence, and
endless patience and tact have to be exercised to combat these recurrent
imperious ideas. The most successful treatment of stammering, a
symptom which is practically confined to psychasthenic individuals,
is by a combination of respiratory, vocal, and articulative exercises,
together with encouraging suggestions of confidence, enabling the
stammerer to make use of his freshly-acquired habits of correct speech.
Tics and habit-spasms, often so inveterate, are also best treated by
a similar combination of suggestion wdth exercises, the physician
first of all being careful to search for, and to remove, any sources of
peripheral irritation, e.g., by correcting errors of refraction and
removing conjunctival irritation in blepharospasm. Writer's cramp
and other occupation -neuroses are rarely cured by suggestion alone.
Here complete cessation from performing the particular action which
induces the spasm or pain is essential, usually for a period of several
months ; and after that, if the action must be resumed, the patient
should learn to perform it in as different a w^ay as possible, so as to
avoid lighting up the old train of morbid suggestions. The various pen-
holders and other apparatus w^hich have been devised for the treatment
of writer’s cramp have their beneficial effect mainly by suggesting new
sensory stimuli instead of the old ones which used to induce the spasm.

Drug -habits — alcoholism, morphinism, cocainism, etc. — are favourably
influenced by suggestion as a valuable accessory. Personally, I confess
to scepticism as to the alleged cure of such habits by suggestion alone.
The pernicious drug has first to be withdrawn. This is not the place
to discuss the precise method of such withdrawal, whether sudden or

SUGGESTION 566 MEDICAL ANNUAL

gradual, or whether and how antagonistic drugs or* antidotes should be
administered. Once the patient has been cut off his drug, then comes
the useful sphere of suggestive-therapeutics, whereby the physician gives
the patient confidence to do his daily work, and to resume his ordinary
life without the use of the drug. The physician should employ sugges-
tions of actual distaste, not merely for the one drug, but for all such
drugs. Thus it is important that a patient who has been cured of a
morphia-habit should also* become a total abstainer from alcohol. I
have repeatedly known the morphine-habit recur when an ex-morphine
patient came later under the influence of alcohol. To influence sufferers
from drug-habits, the physician must gain the patient’s confidence
and his respect, and should encourage him to -report himself at suitable
intervals, partly to verify the patient’s statements, and partly to
strengthen his powers of self-control by suitable suggestions.

Homosexuality and the numerous other varieties of sexual abnor-
mality are -also treated by the psycho-therapeutist, although it must
be confessed that a very large proportion of such cases occurs in
individuals who are congenitally abnormal — moral deviates — and the
chances of cure are not often bright. Nevertheless, it is the duty of the
physician to make the effort to supplant morbid impulses by healthy
ones, by a combination of suitable suggestions with healthy moral and
physical surroundings.

Suggestion may also be employed to influence the functions of
various internal organs, e.g., to combat gastric, intestinal, vesical, and
even uterine disorders, provided always that there is no underlying
organic mischief. Thus in suitable cases nervous vomiting, constipa-
tion, enuresis, dysmenorrhoea, etc., may all be benefited by suggestion.
Whilst it is true that an individual has no direct voluntary control
over the activity of his viscera, nevertheless, the effect of emotions in
producing visceral disorders, such as vomiting, diarrhoea, frequency of
micturition, etc., is familiar to all, and it is by some indirect route of
this sort that suggestive therapeutics act in the relief of visceral neuroses.

Insomnia is sometimes treated by suggestion, but it is only a
small and carefully-selected proportion of cases that are successfully
influenced. It is obviously futile to treat, by this method, cases of
sleeplessness due to such causes as gastro-intestinal toxsemia, persistent
pain or cough, arteriosclerosis, etc.

To sum up, suggestion, like every other method of scientific treat-
ment, medical or surgical, is of value in suitably selected cases, and it
should be the endeavour of the physician to make the proper selection.
The honest psycho-therapeutist will always refuse to attempt treatment
by suggestion in unsuitable cases. To claim that suggestion is a
panacea for any particular class of diseases, even of functional diseases,
is to bring an excellent therapeutic weapon into undeserved disrepute.

References. — Hypnotism,” 5th ed. transl. by Arment, 1906 ; Hyp-
notism,” 4th ed. transl. by Hopkirk, 1909 ; Hypnotism and Suggestion,”
5th ed. 1907 ; Hypnotism,” 1903 ; ^Latham and English’s System of
Treatment, iii, 159 ; Hypnotism and Disease,” 1912 ; Pathogeny of the
Neurasthenic States,” transl. by Richards, 1909 ; ^Bvit. Med. Jour. 1913,
Feb. 22.

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SULPH-H^MOGLOBINiEMIA. Herbert French, M.D., F.R.C.P.

A very noteworthy and probably unique case is recorded by Haldin
Davis. ^ The main symptom was a remarkable coloration of the
face, recalling argyria ; instead of being of the normal pink tint it was
stained a deep slate hue, almost a blue-black. There was no similar
discoloration of the body or limbs. Alkaptonuria, ochronosis, and
argyria were all excluded, and. the diagnosis of sulph-hsemoglobinuria
was established by spectroscopic examination of the blood. What
was most remarkable, hovrever, was that it was only blood obtained
from the head region that gave the absorption bands of sulph-hasmo-
globin ; blood from the fingers showed no abnormality. The fact that
sulph-haemoglobinsemia can thus be localized to the head alone is a new
discovery, and one that must, if confirmed, throw fresh light on the
pathology of this obscure affection. It has generally been attributed
to the absorption of sulphur-containing gases from the bowel, but this
can hardly be the cause in a case in which the blood in the head and
face contains sulph-haemoglobin continuously, whilst that in the trunk
does not. Further results are promised in a future communication.

Reference. — "^Lancet 1912 , ii, 1145 .

SUTURES; Pyiesiley Leech, M.D., F.R,C.S.

Pearson^ draws attention to the fastening of a subcuticular suture by
a shot {Fig, 75). Reder^ suggests knotting the ends of the suture
where they emerge through the skin at each end of the incision. Fine
silkworm gut is used with a fine, straight, triangular-pointed needle.
Halsted,^ of Baltimore, states that the Johns Hopkins school seems
to be almost alone in the advocacy of silk as a ligature and suture
material ; Theodor Kocher has, however, used silk to the exclusion
of catgut, since 1883 at least. Halsted has fine black silk, two or three
yards in length, wound on glass spools which are steamed in heavy

Fig. 75. — Diag^ram of the “Shotted Subcuticular Suture” properly applied. The
continuous line represents the cutaneous incision ; the dotted line the path of the suture
through the corium. Note the points of emergence of the siituie at each end where the
shot IS applied — not in the axis of the incision, but to one sMe.

glass test tubes. From year to year and at various periods he has tried
catgut sterilized by the best American purveyors, but has come back
to the use of silk, as the results have been better. Catgut seems to
irritate the wounds, even if sterile, and he thinks it may serve as a
culture medium for saprophytic organisms which are carried into it
from the deep epithelium and follicles of the skin. Straight needles
may be threaded with fine silk, and basted into strips of thin muslin
and gauze, which may be folded and stored for subsequent use. {Plate
LIT I, Fig. A) illustrates the usual method of controlling hagmorrhage
from the larger vessels which have been isolated. Where they have not
been isolated, the needle is passed first under or between the vessel or
vessels to be ligated, and then a second transfixion is made superficially

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MEDICAL ANNUAL

closer to the point of the clamp and in front of it ; the clamp is
then tilted in the opposite direction, while the operator ties the knot
behind it (Plate LIU, Fig, B), With fine silk one can secure hcemostasis
that is not possible with catgut (as, for example, in the control of
small bleeding points over the trachea, in the pia mater, the periosteum,
and the suture of wounds of vessels). He has seen a ligature of coarse
silk, tied with crushing force, blown off, as it were, from the aorta of a
dog — a ligature which had been applied 12 mm. from the proximal end
of the divided vessel. This same artery was then safely closed by a
ligature of silk, No. a, which pierced it. He seldom uses a coarser silk
than No. c [Plate LIV, Fig, C) for closing long abdominal wounds.
Occasionally he reinforces with one or two sutures of silver wire, which
include skin, and the anterior and posterior layers of the sheath of
the rectus ; otherwise fine silk (Nos. aa, a, and c) is used throughout
for sutures as well as ligatures. He is using the interrupted variety
of suture more frequently than formerly. Silk should not be used
for ligating or suturing in the presence of infection ; it should not
be coarser than necessary, and the parts should not be brought
together under such a degree of tension as to cause necrosis, or inter-
fere greatly with the blood supply. The combined use of silk and
catgut in a wound should if possible be avoided. The epithelial stitch
is made with 00 silk, and a needle to correspond ; this stitch is used in
operations on the dog.

In many operations he uses a fine batiste (sometimes gauze or silk)
dipped in celloidin, to paste over the wound. Since 1894 he has covered
fresh wounds with silver foil. He believes that healing is better under
a moist scab than under a dry one.

References. — ^Med, Press and Circ. 1913, i, 46; ^Surg. Gyn. and Ohst.
1913, Feb. ; ^Joitr, Amer. Med. Assoc. 1913, i, 1119.

SYPHILIS. — (See also Arthritis, Syphilitic ; Cornea ; Ear ; Heart,

Syphilis of ; Liver, Syphilis of ; Syphilis, Cerebrospinal ;

Syphilis, Congenital). C. F, Marshall, M.D.

Etiology. — Recent research seems to throw further light on the
lije history of the Spirocheata pallida, E. H. Ross’- describes intra-
cellular bodies found in the mononuclear leucocytes in 143 cases of
primary and secondary syphilis, and regarded as homologous with
similar bodies (lymphocytosoa) found in guinea-pigs and earth-worms,
and proved to be parasitic. They are of two kinds : in one, the
chromatin subdivides into round or pear-shaped bodies which become
free after the cell containing them bursts ; in the other it develops
spiral coils resembling the Spirocheata pallida, and the spirochacta-like
bodies seen in the intracellular parasites of guinea-pigs and earth-
worms. These bodies were found in chancres, glands, secondary
syphilides, and less often in the blood. They were not found apart
from syphilis, although many controls were made. The bearing of
these facts on the life history of the 5 , pallida may be interpreted
as follows : the spirochaetes are the microgametes or male elements,

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SYPHILIS

and the round or pear-shaped bodies the macrogametes or female
elements. This, however, can only be proved by observing the act
of conjugation. This has not been seen, but further evidence of the
parasite being a protozoon with a cycle of sporogony is found in
the presence of large cells containing numerous chromatin granules,
observed in the deeper layers of secondary syphilides. The technique
by which these parasites were demonstrated, known as the ‘‘ jelly
method,” and invented by H. C. Ross, is fully described in the original
article. After an injection of salvarsan or mercury, the free parasites
diminish in number, but the intracellular remain the same. Ross
concludes with the suggestion that the guinea-pig parasites might
produce in man a mild alfection which would modify human syphilis
in the same way as small-pox is modified by inoculation with cow-
pox. The presumed parasite of small-pox and vaccinia {Cytoryctes)
belongs to a family of intracellular parasites {Chlamydozoa) similar
to the above. Ross’s results have been confirmed by Jennings‘S and
Moolgarkar.'**

McDonagh'^ describes the life cycle of the S. pallida as follows. It
begins with a sporozoite ” or ” infective granule,” which is motile
(? by fiagella). This enters a mononuclear leucocyte, within which it
grows at the expense of its host. The ” sporozoite ” then divides into
two. One half becomes transformed into an irregular coil, subdividing
into shorter coils which eventually become the spirochaetes. The
latter represent the microgamete or adult male element. The female
element develops from the other half of the sporozoite, which becomes
spherical and extracellular. After fertilization, the zygote is said to
divide into sporoblasts, each of which divides into sporozoites, which
start the cycle again. This completes the spore stage, or sporogony.
McDonagh suggests that the syphilitic parasite belongs to the order
ftporozoa, and that an appropriate name would be ” Leucocytozoon
syphilis,'' He thinks that infection is conveyed by the sporozo'ite and
not by the spirochaete, and that recurrent lesions are due to the presence
of .spores, which can start the cycle again. The disco ver^^ of spores
in material from syphilitic lesions is, therefore, important in diagnosis.
The best material for study was from the lymphatic glands. Controls
Irom glands in cases of soft chancre, gonorrhoea, tubercle, and normal
glands were all negative. Pie thinks it probable that the pai’asite of
sleeping-sickness closely resembles in its life history the parasite of
syphilis, and that the bodies figured by Mott are analogous to those
described above. In a more recent paper, McDonagh"’ states that he
has seen the act of fertilization.

SpirochcBta Pallida in General Paralysis. [See also Syphilis,
Cerebrospinal.) — Previous attempts to find the S. pallida in
general paralysis having failed, it was assumed that this disease
(genei'ally regarded as parasyphilitic or metasyphilitic) was due
to the presence of spores or toxins. Recently, however, typical
spirochaetes have been discovered by Noguchi,® using a modification
of Levaditi s silver nitrate method of staining. They were found

SYPHILIS 570 MEDICAL ANNUAL

in twelve out of seventy cases of general paralysis, the clinical
course and post-mortem findings of which wex’e typical of this
disease. They were present in all layers of the cortex except the
neuroglia layer, and were absent from the perivascular sheaths, a fact
which, together with the absence of any clinical symptoms of cerebral
syphilis and the absence of either macroscopic or microscopic gummata
shows that the cases were true examples of general paralysis, and not
of cerebral syphilis, nor of a combination of the two conditions, such
as has been described. Most of Noguchi's cases ran an unusually
rapid course, which may account for the presence of spirochaetes.

These results have been confirmed by Levaditi and Marie, who
found the spirochsete in two out of twenty-four brains examined. In
one case, of seven years’ duration, the organisms were shown by
dark -ground illumination to be alive and active. They were also
demonstrated by various methods of staining, and by the Chinese-ink
method.

Diagnosis. — Cutaneous (“ Liietin ”) Reaction. — Rytina® describes
the same t^^pes of reaction following the intradermic inoculation of
" luetin ” as Noguchi (see Medical Annual, 1913). The normal or
negative reaction may manifest itself by a slight erythema at the point
of injection, which disappears in forty-eight hours, or as a papule
surrounded by an erythematous zone which subsides on the fifth day.
On this account, reactions appearing at this early period have no
diagnostic significance. The positive reactions may be papular,
pustular, or torpid. In the papular form an indurated papule appears
in twenty-four hours and increases for two or three days, becoming
dark red or purple, when it subsides and disappears within seven or ten
days. In the pustular form the papule softens after the fifth day, and
may rupture or become absorbed. In the torpid form the reaction
first resembles a negative one, but becomes papular or pustular in
eight to fifteen days. , In one case this did not occur till the thirty-
sixth day, and on this account Rytina does not consider any reaction
negative until it has been watched for thirty-six days.

The luetin injections are made into one arm and the controls (culture
medium without spirochnetes) into the other. In some cases the
control side showed a papular or pustular reaction similar to the
inoculated side. This is said to be due to a peculiarity in the skin of
syphilitics, especially in tertiary syphilis, which renders it liable to
infection and traumatic irritation. The cause of the luetin reaction is
said to be allergy, or anaphylaxis.

As the result of 117 cases watched for thirty-six days, Rytina comes
to the following conclusions : (i) The test is specific for S37philis, and
was negative in twenty-eight non-syphilitic cases ; (2) In primary

and secondary syphilis it is less constant than the Wassermann reaction,
but in tertiary and latent syphilis, parasyphilis, and congenital s^’philis
it is much more often positive ; (3) The reaction is not inhibited b^^
treatment to the same extent as the Wassermann test ; (4) A negative
reaction is a better criterion of cure than the Wassermann test.

after

LUETIN REACTION

NEW TREATMENT

571

SYPHILIS

Wolfsolin® also concludes that the test is specific for syphilis, and
especially useful in tertiary and latent syphilis and in parasyphilis.
He remarks that it is generally positive in treated cases of congenital
and secondary syphilis, but that intensive treatment in the later stages
produce a negative reaction. Kaliski,^® after an experience with
400 injections of luetin in syphilitic and non-syphilitic conditions,
regards the test as of little value in primary and secondary syphilis
and in parasyphilis, but of service in cerebrospinal and tertiary syphilis.
Benedek^’- regards luetin as useful in the differential diagnosis between
cerebral syphilis and general paralysis. Three cases of cerebrospinal
syphilis gave a strong reaction, manifested by a dark red nodule the
size of a hazel nut appearing on the fifth day in the middle of inflam-
matory swelling. On the seventh day this became pustular and
discharged brownish-yellow contents. In eighty-one cases of general
paralysis there was a positive reaction in 80 per cent, but much less
marked than in the cases of cerebrospinal syphilis. In ten cases of
dementia prtecox, used as controls, there was a weakly positive reaction
in one only {See Plates LV, LVI, Figs. A, B, C, D). Some of the
histological changes which characterize the reaction are seen in Plates,
LVII to LX, Figs. A to H, illustrating Benedek's article. This series
of illustrations is kindly furnished by the Munchenev medizinische
Wochenschrift.

Baermann and Heinemann^^ have tried luetin both in syphilis and
in framboesia (yaws), with a view to differentiating between the two
diseases. They found, however, that there was no difference in the
reactions in the two cases, either with extracts of syphilitic tissues or
with Noguchi's luetin. They also obtained a similar reaction with a
pure culture of the spirochsete of framboesia prepared from unbroken
papules. They conclude that the reaction is specific for syphilis and
framboesia, and that the percentage of positive reactions increases with
the age of the disease and the limitation of the lesions, and also with
the intensity of treatment.

Fischer and Klausner^® have used an extract prepared from the
lung of a syphilitic foetus (pneumonia alba), and state that the cutaneous
reaction obtained thereby is specific for tertiary and hereditary syphilis.
Muller and Stein^^ report similar results with the use of extracts of
the' organs of syphilitic foetus, and consider that a negative reaction
excludes the presence of a gumma. Comparing the results obtained
with such extracts with those obtained with Noguchi’s luetin, they
are nearly identical in tertiary syphilis, but differ considerably in
secondary and latent syphilis and parasyphilis. Whether these
differences are quantitative or qualitative requires further elucidation.

The Wassermann Reaction. — ^Thiele and Embleton^® have endeavoured
to discover the true nature of the antigen and antibody concerned in
the Wassermann reaction. They conclude that the so-called antibody
is not a true one and is not characteristic of syphilis, but is probably
only a stage in the formation of an anti-complementary combination
which develops where there is rapid tissue-destruction, as in acute

SYPHILIS 572 MEDICAI. ANNUAL

infections, narcosis, and death. In all these processes, proteins and
their cleavage products are produced and phosphatids liberated. The
latter foiun new combinations, giving rise to non-specific antigen and
antibody. In sj’philis the destructive process is slow, and the anti-
cornplementary combination is completed by the addition of a lipoid.
The destruction of tissue which occurs after acute infections, narcosis,
and death explains the apparent Wassermann reactions which have
been reported in these conditions, but the authors do not regard them
as true reactions. As regards the antigen, the authors find that the
complement-fixation property does not depend on the presence of
spirochaetes, their products, or changes due to their presence, and that
non-syphilitic extracts bind antibodies as well as syphilitic ones. They
also point out possible errors in the Wassermann test : (i) The antigen
itself may be anti-complementary, and may cause a considerable absorp-
tion of complement, before any inhibition of lysis occurs ; (2) Serums
often contain anti-complementary substances which increase after
keeping.

Major^'* reports the results obtained with the Wassermann reaction
in 1200 cases at the Johns Hopkins Hospital. The technique employed
was that of the original test, except that an alcoholic extract of foetal
syphilitic liver was used instead of a \vatery extract. Positive I'eactions
were obtained in aortic insuMciency (50 per cent), in aneurysm (95 per
cent), in tabes (64 per cent), in general paralysis (92 per cent).
Negative reactions occurred in various brain tumours, multiple sclerosis,
progressive muscular atrophy, Friedreich’s ataxia, bulbar paralysis, and
idiopathic epilepsy. In ten cases of diabetes, only two gave a positive
reaction. As regards the reaction in the cadaver, the author quotes
Bruck’s statement that it is a biological, aiot a cadaveric, phenomenon.
He remarks that to have any value the serum should be tested both
before and after death, for patients may have had syphilis with no
lesions apparent at the autop.sy. In twenty-five cases tested before
and after death, the results agreed in all but one, a case of aneurysm
which had been under intensive treatment. Foerster^’ reports several
cases of untreated tertiary syphilis of the skin and mucous membranes
in which the Wassermann reaction was negative. {Seo also Cerkbko-
sjuNAL Fluid ; Diabetes Mkllitus.)

The HeYmann-Pevutz veaction'^^ depends on the production of a
(locculent precipitate by the addition of sodium glycocholate and
cholcsterin to syphilitic serum. It is described by Jensen and Feilberg^®
as follows : Two solutions are made : (i) Containing 2 grams of sodium
glycocholate and 0*4 gram of cliolesterin in 100 grams of 95 per cent
alcohol : (2) A freshly-prepared 2 per cent solution of sodium glyco-
cholate in distilled water. A 1-20 dilution of the first solution in
distilled water is mixed with an equal quantity of the second solu-
tion, and 0*4 c.c. of the mixture is added to an equal quantity of the
serum to be tested. The serum is first inactivated by heating to 56° C.
for half an hour. The tube is shaken and left at 22° C. for twenty-
four hours. A ilocciilent precipitate indicates a positive reaction.

PLATE LVll.

LUETIN REACTION — HISTOLOGICAL CHANGES

/’/X’. A . — Rapid hection ^ Reichert eyepiece 2, obj. 3) from the circumferential zone of reaction ;
shu\viii.sf diffuse intiltration of the corium, with but few leucocytes in the neighbourim^ epidermis.

/VX'. i>. — Giant cell in the reticular layer of the corium, lying among luimerons epiihelioid celK.
MED ir.-l L A XX UA L,

PLATE LVIII.

LUETIN REACTIO

UKDICAL loif.

PLATE LX.

LUETIN REACTION- contimicd.

M li DICAL A -V .V UA L, jgi^.

NEW TREATMENT

573

SYPHJLIS

Although this test does not give such a high percentage of positive
results as the Wassermaiin reaction, it may be used as a preliminary
test, as it never gives a positive result when the Wassermann is negative.
Lade^® has tried the Hermann-Perutz reaction in 600 cases, and
concludes that it cannot supplant the Wassermann test. lie only
recommends it when the latter cannot be carried out.

Lange's test is a chemical test applied to the cerebrospinal fluid,
and said to be diagnostic of syphilitic and parasyphilitic changes in
the cerebrospinal system. Major Harrison'*^ describes the test as
follows : (i) A solution of colloid gold is made by adding i c.c. of a
I per cent solution of chloride of gold and i c.c. of a 2 per cent solution
of potassium hydrate to 100 c.c. of distilled water. The mixture is
boiled and shaken in a beaker, and then mixed with i c.c. of i per cent
solution of formalin. This produces a purple transparent liquid.
{2) A 0‘4 per cent of pure sodium chloride in double distilled water
is prepared for dilution of the cerebrospinal fluid. The latter is
diluted in series commencing with i-io and ending with 1-40,000
in the thirteenth tube, each dilution being double the preceding one.
Five c.c. of the gold solution are added to i c.c. of each dilution in
separate test-tubes, which are left at room temperature over night.
The reaction consists in precipitation of the gold, which is indicated
in various degrees by change of colour from red to reddish- blue (the
minimum reaction), blue-red, violet, dark blue, light blue, to complete
decolorization (the maximum reaction). The degree of dilution at
which the maximum change of colour occurs is said to distinguish
between syphilitic and non-syphilitic cerebrospinal fluid. Thus in
syphilis and parasyphilis the maximum occurs between dilutions
1-40 and 1-80, while in other cases it occurs at a dilution higher
than 1-320. The test is quantitative as well as qualitative, the
strongest reactions being given by cases of parasyphilis, the next by
cases of cerebrospinal syphilis, and the weakest by cases of secondary
syphilitic headache. Major Harrison's experience so far confix'ms
that of Lange, but further investigation is required before the test can
be regarded as specific. {See also Blood, Examination of.)

Treatment. — At the International Congress of Medicine, Ehidich
stated that the biochemical action of Salvarsan on spirochaetes is not
direct but indirect, a third factor found in the body fluids being
necessary. In a test-tube the spirochaetes fix salvarsan but are not
killed. As I'egards its toxicity, Ehrlich holds that it has no neurotropic
effect, because rabbits showed no lesions of the nervous system even
after injection of large doses. Further, by means of a delicate reaction
with dimethylamidobenzaldehyde, he found that salvarsan has no
affinity for the central nervous system. If a rabbit which has received
an injection of o*ii gram of salvarsan per kilogram is killed soon
afterwards and its nervous system examined with the above test, the
yellow coloration indicative of salvarsan is absent. Again, Ullmann
has shown that after injection of rabbits with salvarsan there are only
minute traces of arsenic in the central nervous system, less than after

SYPHILIS

574

MEDICAL ANNUAL

the* administration of inorganic preparations of arsenic. Degeneration
of the sensory nerves does not occur with salvarsan as it does with
, atoxyl, and according to Ehrlich there is no evidence of any action on
the auditory or optic nerves. He attributes the febrile reaction
following injection of salvarsan to the liberation of toxins set free by
destruction of spirochaetes. Another cause of fever is the use of acid
solutions, which may cause embolism of the lungs, and hence are
dangerous. In answer to those who state that febrile reaction occurs
in non-syphilitic diseases (mycosis fungoides, psoriasis, lichen) after
salvarsan, and attribute it. to cellular destruction, Ehrlich remarks
that it may equally be due to the destruction of unknown pathogenic
organisms, for salvarsan destroys other microbes which may be present
in the body. He attributes neuro-recurrences to syphilis and not to
a toxic action, and considers them due to insufficient doses of salvarsan
which have left foci of spirochaetes in the meninges.

As regards deaths after salvarsan, Ehrlich refers to the 164 cases
collected by Miskdjian, and eliminates 51 which were not directly due
to the drug, and 19 others which occurred in patients weakened by
other diseases or where salvarsan was contraindicated. There remain
94 deaths which he admits may have been caused by the drug, but
he thinks this figure low when compared with the two or three million
injections which have been performed. Against this, he states that
some deaths after mercury have not been published. Ehrlich
emphasizes the danger of salvarsan in inflammations of the nervous
system. Cerebral oedema has often been noticed, and is called by
Miskdjian the nervous form of intoxication, but Ehrlich thinks it is
caused by meningitis set up by a Herxheimer reaction, and explains
affections of the auditory nerve in the same way. In conclusion,
Ehrlich advises caution in the administration of salvarsan, and small
doses to begin with. He thinks it may sterilize syphilis in the primary
stage, and lead to considerable improvement in general paralysis.
Three diseases are absolute contraindications : Addison's * disease,
cancer, and the status lymphaticus.

Neisser is of opinion that there is no spontaneous cure of syphilis by
the formation of antibodies. He considers that mercury and salvarsan
act directly on the spirochaetes, both by destroying them and by
preventing their development. He recommends combined treatment
by Mercury and salvarsan in all cases of syphilis except when there are
contraindications. He thinks that syphilis may be aborted by salvarsan
alone when given soon after infection, but that it is safer to give
mercury as well. At first, mercurial preparations acting rapidly,
such as salicylate of mercury and calomel, should be used, to reinforce
the spirillicidal action of salvarsan ; later on, preparations which
remain in the body and hinder the development of spirochaetes, such
as grey oil. By abortive cure " Neisser means cases in which the
serum reaction has remained negative after repeated examinations
for at least a year. In some, foci of spirochaetes may remain which
are too small to give a positive Wassermann reaction, but such

NEW TREATMENT

575

SYPHILIS

cases are exceptional. Among abortive cures should be included the
results with salvarsan in pregnant women who gave birth to healthy
children. Neisser recommends energetic treatment with salvarsan
and mercury as soon after infection as possible, even when the diagnosis
is not certain. Insufficient doses of salvarsan may do more harm than
good, by leaving foci of spirochaetes untouched. Neisser is of the same
opinion as Ehrlich with regard to affections of the cranial nerves
and " neuro-recurrences,'' that they are due to foci of spirochaetes
in the meninges remaining after too small a dose of salvarsan. Accord-
ing to Neisser, no precise rule can be formulated as to the duration of
treatment, • but he continues till the Wassermann reaction has been
negative after four or five examinations. He also advises examination
of the cerebrospinal fluid before abandoning treatment. When the
serum reaction remains positive, especially in latent syphilis with no
symptoms, he thinks mercury more efficacious than salvarsan, especially
in the form of grey oil.

Of the methods of injection of salvarsan, the intravenous is the more
rapid, the intramuscular the more durable, since it leaves “depots” of
the drug in the tissues. Of the different oily or saline emulsions for
intramuscular injection, Neisser prefers the Joha saline suspension.
Comparing salvarsan with Neo-salvarsan, the former has a stronger*
action on spirochaetes and the latter is liable to decomposition. As
regards dosage, Neisser begins with a small dose of o-i to 0*2 gram
repeated three times, then larger doses of 0*4 to 0*6 gram at intervals
of ten days, the total quantity in a course of treatment being from
2|- to 3 grams for a man and 2 grams for a woman.

Neisser considers that the accidents after salvarsan have been
exaggerated. Among the causes of such accidents he mentions
oxidation of the drug b3^ exposure to the atmosphere ; impurity in the
water or saline solution ; idios^mcras^^ or hypersensibility of the
patient, manifested by congestion of the brain with oedema up to
haemorrhagic encephalitis ; incorrect dosage, either too large doses
or too long intervals. Many secondar^j^ effects are due to the action
of salvarsan on the spirochaetes b}’’ setting free endotoxins, and to
phenomena comprised under the name of the J arisch-Herxheimer
reaction. Hence it is wise to commence with small doses, and in some
cases to use mercury before giving salvarsan. Schreiber has only
had three deaths in 7000 injections of salvarsan, one an alcoholic,
another in general paralysis, while the third died of pneumonia.
He considers that it has no bad effect on the nervous system, and
attributes neuro-recurrences to insufficient doses. Contraindications for
salvarsan are limited by Neisser to severe alcoholism, cadhexza, hepatip
affections, and degenerative lesions of the nervous system. He claims
favourable results in aortitis and aneurysm and in early cases of tabes,
but not in general paralysis.

Blaschko thinks it is too early to form a definite opinion on the
results of salvarsan ; we should wait ten years before speaking of a
radical cure of syphilis.

SYPHILIS

57 <>

MEDICAL ANNUAL

Hallopeau still considers that Hectine is superior to salvarsan,
because its administration can be continued for long periods without
the dangers connected with salvarsan. He recommends ten courses
of forty daily subcutaneous injections of 0*3 gram of hectine, with
five days’ interval between the courses. The first few injections should
be made in the neighbourhood of the chancre.

Ehlers claims that results as rapid as those of salvarsan can be
obtained by supermaximal doses of mercury. For this purpose he
gives an initial intramuscular injection of Benzoate of Mercury, followed
by a course of inunction. The dose of benzoate recommended is
15 cgrams for a woman and 20 for a man, or 2J mgrams per kilo
of body weight. He reports 248 cases injected with doses of 10 cgrams
and upwards of benzoate of mercury, with good effect in most. Stoma-
titis occurred in 43 cases and temporary diarrhoea in a few. One case
of malignant syphilis died owing to neglect of precautions. Chancres
and ulcerative syphilides healed in a few days, but the action was
slower on papular syphilides. In primary syphilis, secondaries were
prevented. By means of these large initial doses Ehlers thinks that
an ictus therapeuticus can be attained.

Gibbard and Harrison^* report their results with Salvarsan and Neo-
salyarsan at the Military Hospital, Rochester Row. Comparison of
cases treated b}" mercury alone with those treated by salvarsan were
in favour of salvarsan as a routine method. Out of 162 patients
treated with intravenous injections of salvarsan, either alone or in
conjunction with mercury, and observed for periods ranging from six
to twenty-one months, ii relapsed. Out of 102 cases well treated
with mercury, observed for six to twelve months, 85 relapsed. The
average period during which the salvarsan relapses remained free from
symptoms was seven months, while the mercurial relapses occurred at
an average of four months. In 56 cases of primary syphilis treated
with salvarsan and observed for periods of six to twenty-one months,
only two developed secondary symptoms, while in 23 primary cases
treated wdth mercury and observed for twelve months, 21 developed
secondary symptoms. As regards the Wassermann reaction, 16 per
cent were positive four to seven months after treatment with salvarsan,
57 per cent five months after treatment with mercury. Five cases of
reinfection occurred among cases treated with salvarsan. The routine
treatment recommended is an initial intravenous injection of o*6 gram
salvarsan, then nine weekly intramuscular injections of mercurial
cream, lastly?- another injection of salvarsan. The blood is examined
every three months, and if the reaction is positive the above course is
repeated. These workers have had no deaths and no cranial paralysis
in upwards of 2000 cases. They attribute nervous s^miptoins to
syphilis, and not to the neurotropic action of salvarsan, and consider
that znost deaths have been due to faulty technique or disregard of
contraindications. In the fatal cases where epileptiform convulsions
and coma occurred, they do not accept Ehrlich’s explanation, that the
symptoms are due to liberation of endotoxins from spirocha^tes in the

NEW TREATMENT

577

SYPHILIS

meninges, because these cases generally followed the second and hot
the first injection. They think rather that the effect is due to the
Cumulative effect of arsenic in susceptible persons. This view is
supported by the production of similar symptoms in rabbits by over-
dosing them with salvarsan, in which cases spirochaetes were out of
the question. As regards neo-salvarsan, these observers consider it
less suitable than salvarsan owing to its instability.

Neisser‘2^ discusses the changes which have taken place in the treat-
ment of syphilis since 1902, when the following principles were laid
down : (i) General treatment should be begun as early as possible ;
(2) The treatment should consist in several repeated courses of
mercury, sometimes energetic, sometimes mild ; (3) It should be

continued for at least four or five years in all cases of syphilis, even in
absence of symptoms ; (4) Whenever possible, local treatment should
be added, especially in contagious lesions of the skin and mucous
membrane. The first principle holds good, for the value of early
general treatment has been confirmed by experiments on animals, and
by the discovery that general infection of the body takes place at an
early period after infection. As a rule, early treatmeirt should depend
on the certain diagnosis of syphilis, but in some cases Neisser recom-
mends it even when this is uncertain ; for example, in married men
and in those about to be married, because on the one hand there is a
good chance of cure, and on the other hand serum diagnosis will show
in later years whether syphilis is present or not.

As regards the chronic intermittent” treatment formerly advocated,
Neisser considers that it should be chronic but not intermittent.
Although symptoms may disappear and the reaction become negative
after a single course, relapses with a positive reaction may occur after
a year’s interval. Therefore the treatment should not be omitted for
any length of time. The arguments against the intermittent plan are
the facts that the best results are obtained by treatment in the early^
stages, and that spirochaetes may become encapsuled during the
intervals. Hence treatment should be fairly continuous during the
first year or two. Neisser does not place much reliance on the body’s
power of resistance, and advises energetic treatment with antispiro-
chaetal drugs. As to the duration of treatment, Neisser considers
this question still unsettled, although the Wassermann reaction is
of assistance. He thinks a positive reaction an indication for further
treatment, while repeated negatives suggest a cure but ai*e not con-
clusive. In order to prevent tabes and general paralysis, the cerebro-
spinal fluid should be examined, for this may show serological,
microscopical, and chemical changes in the absence of clinical symptoms.
As regards the therapeutic measures, Neisser advises Salvarsan,
Mercury, and Iodides in all cases, together with Hydrotherapy, any
contraindications being observed in each patient. Local treatment
should include dissection of the primary sore.

Finger--'* considers that neither mercury nor salvarsan has any
direct antiparasitic action, and that their effect is indirect by stimulating

SYPHILIS

57S

MEDICAL ANNUAL

the production of protective substances. He concludes that salvarsan
is useful in combination with mercury in primary cases with a negative
Wassermann reaction, and also in tertiar)?- syphilis when rapid action
is required, but that in primary cases with a positive Wassermann, and
in the early secondary stage, it is best omitted, owing to the danger
of haemorrhagic encephalitis. He points out that the future of patients
treated with salvarsan, as regards parasyphilis (tabes, aortitis, and
general paralysis), remains to be seen.

Corbus-® recommends intravenous injections of salvarsan combined
with mercurial inunction, and continuous treatment for at least nine
months after the Wassermann reaction is negative. Touton-^ adopts
the same treatment in most cases of syphilis, and says that tabes,
leucoplakia, aortitis, and general paralysis are benefited b}' it. In
cases of cerebrospinal s^^philis and in neuro-recurrences,” which he
regards as syphilitic in nature, Dreyfuses advises energetic combined
treatment. For this purpose he gives intravenous injections of 0*4 to
o»5 gram salvarsan, and twelve calomel injections of 0*05 gram during
a course of six to eight weeks, the total amount of salvarsan being
5 to 6 grams. Kilroy^^ reports good results with two to four intra-
venous injections combined with mercurial treatment in 1000 cases
at the Royal Naval Hospital, Plymouth. Kren-'^^ concludes that
sSah’-arsan is especiall}’’ valuable in primary, tertiary, and hereditary
syphilis, less so in secondary syphilis, and unfavourable in tabes and
general paralysis. He considers high arterial tension, severe nervous
affections and non-syphilitic disease of the middle and internal ear to
be contraindications. AntonP^ reports seven cases of reinfection
(fresh primary and secondar3’ S3q)hilis) after treatment with salvarsan
and mercuiy.

Klausneri^ remarks that salvarsan cannot replace mercurial treatr
ment, and that an active preparation of mercury is an essential adjunct
to treatment by salvarsan. .He recommends a prei^aration devised
by Richter®^ and termed Gontraluesin,” which consists of a mixture
of sozoiodolate of mercury, quinine, and salicylic acid, the mercury
being in such a finely divided state that it can enter directly into the
blood-stream. This is given by intramuscular injection in doses of
0*15 gram mercury every five days. The syringe must be all glass,
without metal, on account of amalgamation with the mercury. Syringe
and needle must not come in contact with water, and should be kept
in spirit soap. Klausner reports good results in cases of primary,
secondary, and tertiary S3TphiIis.

Kolle,^'* by experimenting with various mercurial preparations on
the spirillosis of fowls, concludes that the best preparation for combined
treatment with salvarsan is Mercury-sulfamino-dimethyl-phenyl
pyrazolon. Arbour Stephens^® reports six cases of syphilis, one
primary and five tertiary, in which the ulcers healed after subcutaneous
injection of 6 to 10 c.c. of Distilled Water. He attributes the result
to the production of antibodies by diminution of surface tension in the
body fluids caused by the distilled water, and compares tlie results

NEW TREATMENT

579

SYPHILIS

obtained with distilled water with those obtained by salvarsan. He
regards the Wassermann reaction as a roundabout way of determining
the surface tension at which haemolysis occurs.

Rajat^"® recommends rectal administration of salvarsan. The rectum
is first washed out with water. The dose of salvarsan is dissolved in
120 c.c. of artificial serum in the proportion of 5 per 1000, with the
addition of soda if necessary for complete solution. The salvarsan
enema is retained for thirty-six to forty-eight hours. After experience
with 125 cases, the author maintains that the effects obtained are the
same as after intra\'enous injection, and that the rectal route is free
from the dangers of other methods.

DudumP’ concludes that Hectine alone is sufficient to heal ciitajieoiis
syphilides and gummata, whether ulcerated or not, without the aid of
other treatment, but that mercury and iodides should be administered
after these lesions are healed. The drug is given by daily intramuscular
injection of 0*2 cgram ; from five to twenty -five injections in all.
The author thinks that hectine compares favourably with salvarsan,
and is free from the dangers and complications which are associated
with the latter drug. He considers that it is useful in all stages of
syphilis, but that it cannot replace mercury.

JeanselmeandVernes^® state that syphilis can be aborted or sterilized
by salvarsan in the primary and early secondary stages. In 16
cases of primary syphilis secondary symptoms were absent during
periods of observation ranging from five to nineteen months, 8 cases
being observed for more than a year. In 6 cases treated in the
eaidy secondary stage, there were 3 failures, 2 successes which
remained free from further symptoms for eighteen and nineteen
months respectively, and i case in which reinfection occurred. The
number of injections w^as from two to six, usually five or six. The
doses were 0*3 gram for the first and 0*4 to 0*5 gram for the subsequent
injections, occasionally o*6 gram. The total amount of salvarsan
required for sterilization was estimated at 2 grams. These observers
attribute failure of abortive treatment to insufficient dosage, and
remark that it is better not to use salvarsan at all than to use it too
timidly. L. Bing, on the other hand, does not believe that syphilis can
be sterilized by salvarsan, even by repeated inj ections in the early stages.
In 10 cases of primary syphilis, with chancres dating from three to
fifteen da^^s, treated with two to seven intravenous injections of 0.4
to 0*6 gram of salvarsan or 0*45 to 0.75 gram neosalvarsan, secondary
syphilis followed in all but 3, and in these the Wassermann reaction
remained positive.

Wansey Bayly®® discusses the dangers and complicaiions of salvarsan
injection. He considers that there is still a risk to life, but that this
is very small. He groups the fatal cases under four headings, those
with symptoms of (i) meningitis, (2) nephritis and uraemia, (3) toxaemia
associated with hepatic degeneration, (4) pulmonary embolism. In
most cases the symptoms have occurred after the second dose of
salvarsan. Both acute nephritis and fatty changes in the liver-cells

SYPHILrS

580

MEDICAL ANNUAL

have been produced by experimental arsenical poisoning, and similar
eflects may be due to toxic doses of salvarsan. Bayly is of opinion
that deaths occurring under the first three headings are the result of a
CLunulative action, and that some patients are especially susceptible
to salvarsan. As regards complications, the most dangerous are due
to the toxic action of the drug, especially on the meninges. As a sign
of toxic action he mentions conjunctivitis, which is an early sign of
intolerance. He does not think there is any danger to the optic nerve.
He attributes fever in some cases to impurities in the saline solution,
in others to liberation of endotoxins from destroyed spirochaetes. In
order to avoid complications, Bayly recommends (i) Lowering the
blood-pressure, so as to accommodate the extra amount of fluid, by
giving a pill the night before and a saline purge the morning of injection,
and by withholding food and drink for five hours ; (2) Fresh preparation
of solution immediately before use ; (3) Rest in bed for twenty -four
hours after ; (4) The drinking of large quantities of barley-water and
a milk diet for tweiity-four hours ; (5) Absolute rest of limb in case
of phlebitis, to avoid pulmonary embolism ; (6) Intervals of a week
between the injections.

Mouneyrat‘^° has invented two new arsenical compounds which are
said to be as effective as salvarsan on spirochaetes and trypanosomes,
and free from the neurotropic and congestive action of this preparation.
These compounds are called Galyl and Ludyl, the former being tetra-
oxydiphosphaminodiarsenobenzene, the latter phenyldisulfamino-
tetraoxydiaminodiarsenobenzene. Experiments on animals showed
a mai*ked action on Trypanosoma gamhiense, the spirilla of African
recurrent fever, and those of the spirillosis of fowls. In human syphilis
remarkable results were obtained in 220 cases. Chancres healed in
from two to twelve days, and cases treated in the primary stage
remained free from secondaries. Mucous patches, erosive and papular
syphilides healed in a few days, and gummatous infiltrations in ten
to twenty days. The Wassermann reaction usually became negative.
These drugs may be given by intramuscular injections of an oily
suspension containing 20 to 30 cgrams, or by intravenous injections
of a solution in distilled water in doses of 40 to 50 cgrams for a woman
and 45 to 60 for a man. Three weekly injections are usually enough.
The injections are said to be well tolerated, and no albuminuria or
affections of the optic and auditory nerves were noted,

Tsuzuki'^^ has tried a combination of bitartrate of potassium and
ammonium with oxide of antimony, which he terms “ Antiluetin.” This
is given according to the formula : Antiluefin 2*5, cocaine hydro-
chloi'ate 2*5, distilled water 100 grams ; i to 2 c.c. for a dose. Cocaine
is added because the injection is painful. It is made subcutaneously
between the shoulders, beginning with a dose of *025 gram, and gradu-
ally increasing to *05 gram, till a total of *15 to '3 gram is given during
four or five days. Tsuzuki reports good results with antiluetin, whether
alone or in combination, in primary, secondary, and tertiaiyr syphilis,
including a case of cerebral syphilis and one of optic atrophy.

NEW TREATMENT

53i

SYPHILIS

Bruck and Gluck^- report good results with intravenous injections
of Cyanide of Gold and Potassium, in doses of *oi to *03 gram. The
effect in tertiary, syphilitic ulceration is said to be nearly as rapid as
with salvarsan.

Bernard-*^ has tried the following intensive treatment in five cases
of secondary syphilis which were observed for about two years, no
further symptoms appearing and the Wassermann reaction remaining
negative. The scheme of treatment was, for the first three da3^s,
90 gr. of potassium iodide daily ; fourth day, cathartics and Turkish
bath ; fifth day, intravenous injection of *6 gram salvarsan ; sixth
and seventh days, rest ; eighth to twenty-second day, intravenous
injections of mercuric chloride daily, beginning with -1- gr. and rapidly
increasing the dose to the maximum ; twenty-third to twenty-sixth
day, 90 gr. of potassium iodide daily ; twenty-seventh day, cathartics
and Turkish bath ; twenty-eighth da}’-, salvarsan as before ; twenty-
ninth and thirtieth days, rest ; thirty-first to forty-eighth day, mercuric
chloride injections as before.

McMurtry'*-^ remarks that although salvarsan is a remedy with
remarkable action, the use of mercury is still universal. He believes,
therefore, that any measure is valuable which tends to make intense
mercurial medication s^fer and more effective. For this purpose he
advocates Sulphur, either in the form of natural sulphur waters or as
precipitated sulphur. Sulphur aids the absorption of mercury, and
also its elimination, and hence tends to prevent mercurial poisoning.
According to McMurtry, sulphur is indicated (i) In intensive mercurial
treatment ; (2) When the assimilation or elimination of mercury is

deficient ; {3) As a routine treatment after a course of mercury ;

(4) In habituation to mercury, when the tissues have lost their power
to react to the drug and may be “ resensitized ’’ by sulphur ; (5) In
malignant, obstinate, or constantly recurring lesions ; (6) When

encapsuled' masses of mercury are left after intramuscular injections
of insoluble preparations ; (7) In intolerance to mercury ; (8) In

syphilitics who suffer from anaemia, gout, rheumatism, cachexia, and
debility ; (g) In mercurial poisoning ; (10) In intolerance to iodides.

The contraindications are said to be pregnancy, hepatic disease, visceral
congestion, arteriosclerosis, severe nervous disease, active tuberculosis,
and gastric intolerance.

Congenital Syphilis {See also Syphilis, Congenital). — Levy-Bing
and Duroeux^^ recommend a varied treatment in syphilitic sucklings.
Mercury and arsenic are indicated in general eruptions, mercury and
iodide in infiltrated lesions, and also in congenital dystrophies. Mercury
is well tolerated by infants, provided the liver and kidneys are sound.
It may be given : (i) By inunction, in the form of equal parts of
metallic mercury and benzoated lard, i gram being rubbed in daily
into various parts of the body ; (2) By the mouth, in the form of

Van Swieten's liquor (i-iooo alcoholic solution of mercuric chloride),
given in gradually increasing doses of 10 to 15 drops in the first week
and 30 or 40 drops in the fourth week, up to 4 or 5 grams at the end of

SYPHILIS 582 MEDICAL ANNUAL

ii year, also in the form of grey x^owder ; (3} By injections in the form
ot biniocUcle of mercury (biniodide of mercury and x'^otassium iodide i
gram of each in 100 c,c. of distilled water), or benzoate (i gram in
100 c.c. of isotonic serum) in doses of mgram per kilo of body
weight, injections being made daily into the buttocks in series of
fifteen. In older children, insoluble injections of calomel or grey oil
may be used. As regards Iodide of Potassium, ‘05 to *15 gram may
be given daily during the first year when indicated. They are not
in favour of salvarsan in the case of infants.

Simpson and Thatcher,^® on the other hand, report good results
from salvarsan treatment in forty cases of congenital syphilis varying
in age from a month to eleven years The method used was that of
direct injection into the external jugular vein after cutting down on
it. The dose was -oi gram per kilo of weight. Rapid improvement
was obtained in cutaneous eruptions, on^^chia, epiphysitis, enlarged
spleen and lix^er, cervical adenitis, synovitis of the knees, keratitis and
irido-cyclitis, and guinmata. There were seven deaths, six in children
under six months old ; two had severe syphilitic pemphigus, one
was marasmic, two died later of broncho-pneumonia and one of con-
vulsions ; one death was perhaps due to impure distilled water. The
remaining 33 cases did well. The authors conclude that salvarsan
can be given safely to the youngest child with proper dosage and
technique. In severe cases, such as those with bullous syphilides or
marasmus, the dose should be less than ’Oi gram. They advise
mercurial treatment in addition, but mention that some cases did well
with salvarsan alone. They do not regard the Wassermann reaction
of much use as an index of the efficacy of treatment.

Treatment of Syphilis in Pregnant Women . — At the Fifteenth
Congress of the French Obstetrical Society,^ ^ this subject was
discussed. Sauvage reported on 130 cases. He first drew attention
to the action of Salvarsan on the liver and kidney. Reducing
substances and sugar may be present in the urine, possibly due' to
the excretion of salvarsan. Albuminuria may be intense, but may
disappear Avith appropriate diet. Jaeger reported severe nephritis
and Gaucher a fatal case. Bar described a case which died of
haemorrhage into the central nervous system after injection of
neo-salvarsan. Salvarsan is indicated during pregnancy when other
treatment is insufficient. It is contraindicated in all cases where
careful examination of the patient may foreshadow a possibility of
accidents. These may be due to arsenic or to toxins liberated by
destruction of spirochcetes. The excretion of arsenic depends on the
integrity of the liver and kidneys, and is more rapid with salvarsan
than neo-salvarsan. Excretion of arsenic may be less than the quantity
injected ; hence great prudence is necessary in the administration
of salvarsan during pregnancy. It does not appear to raise arterial
tension, but because of the accidents which may accompany hyper-
tension it is best avoided in pregnant women who have a high blood-
pressure. The action of salvarsan on the spirochaetes is generally

NEW TREATMENT

583

SYPHILIS

rapid, but after an insufficient dose these ina)' reappear in the lesions.
The action on the Wassermann reaction is variable and inconstant,
and may be transitory. In a case reported by Bar, the reaction
remained positi\’e after live injections of salvarsaii and eight of neo-
sah’arsan. The contradiction which may exist between the clinical
symptoms and the Wassermann reaction renders the action still more
uncertain.

The passage of salvarsan to the foetus has been denied by several
observers, but others have found arsenic in the blood of the umbilical
cord a few da^^s after the injection. The Wassermann reaction often
differs in mother and child, and is generally more positive in the latter.
As regards the effect of salvarsan on labour, analysis of 84 cases showed
that labour was precipitated only in three, and those near term. On
the contrary, salvarsan seems to favour the evolution of pregnancy,
since in these 84 cases, 38 were delivered at term, 32 in the ninth month,
and 12 in the eighth. The action on primaiy and secondary lesions
of the mother is rapid, but these lesions may recur during or after
pregnane}’. The foetus appears to be affected by injection of salvai’san,
for three cases of death in utero have been published ; this danger,
however, seems to be small. On the other hand, salvarsan appears
to protect the life of the infant against maternal infection during
intra-uterine life, for out of 91 infants, 84 were born alive (92 per cent) ;
but a certain number of infants bom apparently healthy after treat-
ment of the mother with salvarsan during pregnancy are potentially
syphilitic, and it is impossible to estimate the proportion. Therefore,
all such infants should be treated after birth, and should never be given
to a Avet-nurse.

SauA^age next considers Mercurial treatment during pregnanc}’.
For this purpose he has collected the statistics of Pinard, Champetier
de Ribes, Boissard, and Potocki. In the first group the Avomen had
actiA’e syphilis during pregnancy and Avere submitted to mercurial or
mixed treatment. In 133 out of 217 cases, or 6 t per cent, this Avas
incapable of healing activ’e syphilitic lesions. In 74 per cent of these
cases the child AA’as born dead or died soon after birth ; 10 per cent
Avere born Avith signs of syphilis. In a second group there were no
signs of syphilis during pregnancy. Mercurial or mixed treatment
Avas giA^en during pregnancy, and in’egulaiiy before fecundation. Out
of 163 cases of this kind, 66 infants Avere born alive Avith no signs of
syphilis at birth, 14 per cent had signs of syphilis at birth or soon after,
and 19 per cent Avere born dead or macerated. The third group
comprises cases with no symptoms during pregnancy, but with regular
mercurial treatment before fecundation and during pregnancy. In
128 cases of this kind, there Avere 88 per cent living infants. Hence
mercurial treatment, to be most successful, requires to be prolonged.

It should be commenced at least six months before conception, and
continued during pregnancy.

Salvarsan is only indicated in cases AA'-here the woman has not received
regular treatment before fecundation, and in cases of active syphilis

SYPHILIS

584

MEDICAL ANNUAL

during pregnancy, whether due to recent infection or relapse of former
syphilis. In such cases it gives results where mercury has failed.
Also, the 92 per cent of infants born alive after salvarsan compared
with the 74 per cent born dead after mercury is in favour of the former
treatment, in cases of active lesions during pregnancy. When the
woman has no active signs, but has not received regular treatment
before conception, Sauvage thinks that salvarsan should be used with
prudence, if at all. The two deaths reported above were under these
conditions, and with mercury 66 per cent of infants were born alive
under the same conditions. The Wassermann reaction cannot be
depended upon as a guide, and clinical examination is still, and
should remain, the only indication for treatment. Before administering
salvarsan, the patient should be examined for any contraindications,
especially insufficiency of the liver and kidney and idiosyncrasy to
arsenic. The doses should be small and frequent, and the excretion
of arsenic should be tested regularly’. However, good results have
been obtained after a single injection of salvarsan followed by mercurial
treatment. Lastly, treatment should be begun as near as possible
to the commencement of gestation, before the spirochaetes have caused
severe visceral lesions in the foetus.

Chambrelent analyzed the results of salvarsan treatment oiT the
infant, including indirect treatment through the mother or with the
milk of a goat injected with salvarsan, and direct treatment of the
infant. In 51 cases of indirect treatment through the mother, 27
were improved, 24 were not improved or relapsed, and 8 died. It is
impossible to say whether the deaths were due to disease or treatment.
I'lie mechanism of this treatment is doubtful. The quantity of
salvarsan excreted in the milk is uncertain. Some observers think
that the effect is not due to arsenic, but to antibodies formed in the
mother which pass to the infant by the milk ; but, as Chambrelent
points out, if this is the case the effect can only be transitory, for the
syphilitic antibodies must be incapable of killing all the spirochaetes
in the infant. However, he thinks that the indirect method should
not be abandoned, but should be reserved for cases where the mother
has active lesions which may be benefited by salvarsan. As regards
the direct method, Chambrelent collected 38 cases in 1910, 25 of which
were improved and 13 died ; but in 1911, when the technique had been
improved, the total of cases published gave 55 improved and onl}^
four deaths. In 1912 numerous cases were published : Engelnianu
reported seven cases wdth 3 deaths, but the doses were too large ;
Welde, 28 cases (subcutaneous, intramuscular, and intravenous
injections), with 5 deaths due to other causes ; Heubner and
Noeggerath, 28 cases - with 9 deaths (intravenous injection of 2
mgrams per kilo repeated several times, up to i egram per injec-
tion) ; Scoffier, to cases with good results with subcutaneous injections
of I egram per kilo. Chambrelent concludes that direct injection of
the infant appears to be the best method, but it must be used with
great caution. It is indicated when the infant presents severe cutan-

NEW TREATMENT

585

SYPHiLIS

eons lesions, and when mercurial treatment has failed. He considers
intravenous injection dangerous, and subcutaneous or intramuscular
injection preferable, especially since the introduction of neo-sal varsan.
The dose should be from 10 to 15 mgrams per kilo of weight.

Fabre and Bourret consider that the indications for intravenous
injection of women with no S3?mptoms,.with the object of prophylactic
treatment of the infant, are very restricted, and limited to failure of
mercurial treatment during previous pregnancy and intolerance of
mercury ; but when active symptoms are present in the mother,
they think that salvarsan is more often indicated. They limit the dose
to 0*3 gram. These observers also report on 20 cases of intra-
muscular injection of infants. Neo-salvarsan is more easy to inject,
and is less liable to cause induration and muscular necrosis. Three
cases died, but they only attribute this result to the drug in one case,
which developed haematuria and died in ten days after an injection
of 2 cgrams. In all the other cases the results were good, especially
in syphilitic pemphigus. When the infant is heredo-syphilitic but has
no active lesions, the benefit derived from salvarsan is doubtful, and
it seems to have little effect on the general condition, Moreover, its
action on the lesions is only transitory, and recurrences are frequent.
Hence, treatment must be continued by mercury and iodides.
Salvarsan injection should only be repeated when lesions reappear in
spite of mercurial treatment. These observers are therefore in
favour of combined treatment by salvarsan and mercury.

Lemeland and Brisson report the results of 52 cases of pregnant
women treated by salvarsan and neo-salvarsan. They conclude that
salvarsan has no effect on the course of labour ; that it has a favourable
effect on the foetus, that the doses should be small (below 0*5 gram);
that a second injection should not be given unless the elimination of
arsenic is normal after the first injection; that neither' salvarsan nor
neo-salvarsan in non-dangerous doses renders the Wassermann
reaction definitely negative ; that the action of salvarsan and
neo-salvarsan on the foetus appears certain, but neither of these
drugs is without danger ; that the action on the infant is variable, and
dangerous in severe infections ; that neo-salvarsan is more dangerous
than salvarsan ; that these two drugs may favour syphilitic infection
of the nervous system ; finally, that the difficulties of preparation,
the necessity of estimating the excretion of arsenic, and the dangers
connected with this treatment, render it an exceptional and not a
routine form of treatment.

Bar finds that salvarsan does not cure syphilis and seems to pre-
dispose to neuro-recurrences. Salvarsan is a powerful remedy but a
dangerous one, and it is doubtful whether the dangers are avoided by
smaller doses. He considers it necessary to estimate the excretion of
arsenic, and, if it is arrested, to abstain from repetition.

References.— M ed. Jour. 1912, ii, 1651 ; ^Jbid. 1655 ; ^Ibid. 1655 ;
^Lancet, 1912, ii, loii ; ^Brit. Jour, of Dermatol, 1913^ Jan.; ^Jour. Exper.
Med. 1913, 232 ; ’Bw//. Soc. de Biol. 1913 ; ^Med. Rec. 1913^ 3^4 ; ^Jour.

SYPHILIS

5S6

MEDICAL ANNUAL

.Uncr. Mctf. .Is^oc. 191J. i. iJS55 ; ^Jed. Junr. 191.^, i, 2 \ ;

uicd, Woch, 19*3. ; ^'^Ibid. l^^‘J \ 'HVieu. Idin. Wvch. 191^^. 997 and

973 : ^Ubi(L 825 ; f. Inimituitatsforschung. 1912, >kl. vi. 4,^0;

Hop, Hasp. Bti'lJ. 1913. 175; Cutan. Dis, 1913, 393; ' Klin,

igix. No. 2 ; ^'^BerL kliji. Woch, 1912, June. Byit. Med. Jour. epit. 1912.
Oct. 12 ; -^^Deut. med. Woch. 1913^ <^93 ; ^^^Manual of Venercd Diseases,
London, 1913, 126; -KAnn. des Mai. F^?m.-I 9I3. Oct.; Med. Jour.

1912, ii, 953; ^^^Berl. Jtlin. Woch. I9i3> 49; ^^Wien. him. Woch. 1913/561 ;
^^Jo'ur, Amer. Med, Assoc. 1912, ii, 1267; ^"^Berl. klin. Woch. 1913, 573;
^^Munch. med. Woch. 1912, 1857 ; '^^Lancet, 1913, i, 302 ; ''^HVien. /din. Woch.
1913^ 133 ; ^^Deut. med. Woch. 1913, 506 ; '•^^Munch. med. Woch. I9i3> 62 ;
^‘^Dennatol. Woch. 1912, Bd. 55, 1218 ! ^^Deut. med. Woch. 1912, 15S2 ; ^^Brit.
Med. Jour. 1913, i, 706; ^^Ann. des Mai. Vhi , 1912, Nov.; ^’’Ihid. 1913,
Mar. ; ^^Paris Med. 1913. Mar. ; ^^Lancet, 1913, i, 1443 ; "^^Presse MM. 1913,
388 ; ^^ Deiit . med . Woch . 1913, 988 ; ^^ Miinch . med . Woch . 1913, 57 ; ‘^^ N . Y .
Med . Jour . 1913. L 12S5 ; -^^ Jour . Cutan . Dis . 1913, 474 ; '^^ UE ' tJance , 1913.
Jan. ; ^^ Brit . Med . Jour . 1913, ii, 534 ; ^"^Presse Mid . 1912, 989.

SYPHILIS, CEREBROSPINAL. {See also Cerebrospinal Fluid.)

Pitvves Stewart, M.D., F.R.C.P.

Dementia Paralytica. — The Diagnosis of general paralysis in its
earlier stages has, within the last few years, made notable advances,
mainly owing to a s^’stematic examination of the cerebrospinal fluid in
suspected cases. The clinical signs which should lead the physician
to suspect general paral^^sis, and to apply laboratory tests to the blood
and cerebrospinal fluid, are discussed by Geo. M. Robertson^ in his
masterly Morison lectures of 1913. When clinical and laboratory
tests are thus combined, there are only two other conditions in
which there is any uncertainty with regard to the presence of general
paralysis, namely, when mental symptoms exist in connection with its
twin-sister, tabes, or its first cousin, cerebrospinal syphilis.”

In the early stages of general paralysis, the patient is not insane : he
is merely a changed man. There is an alteration in his intelligence,
character, habits, and feelmgs, and this change is for the worse. For-
getfulness is usually a noticeable symptom, and the habits of social
courtesy, of decent behaviour, and of personal honour, may be departed
from, all of these early symptoms being traceable to a loss of the finer
feelings and to impairment of memory. Although, at this stage, the
symptoms do not amount to actual insanity, nevertheless they indicate
a serious deterioration of intelligence, and, if associated with the
physical signs of general paralysis, to be mentioned presently, should
not be overlooked. These occasional mental failings may be present
for a year or more before serious and continuous signs of certifiable
mental disorder become superadded. Many a case of early general
paralysis is regarded as merely neurasthenic or, at most, melancholic.
But in this melancholia of early general paralysis there is always some-
thing atypical. Thus, for example, the patient may eat ravenously,
or sleep soundly, or make silly remarks, or show great loss of memory,
none of which are typical of common melancholia.

For the diagnosis of general paralysis it is important to bear in mind
the combination of mental symptoms with physical signs. The disease
should be recognized long before the grandiose delusions of the second

NEW TREATMENT 587 SYPHILIS, CEREBROSPINAL

stage iiave supervened. The physical signs that shoxild lead us to
suspect early general paralysis are, generally speaking, those also
found in tabes dorsalis, with or without certain additional occurrences
forming no part of the tabetic syndrome, e.g., a convulsive seizure,
temporary aphasia, or an attack of unconsciousness. The pupils are
usually unequal (although mere inequality hy itself, unless ver}?’ marked,
is of little diagnostic value). Their outline is frequently irregular,
but the most important pupillary sign is the well-known Argyll-
Robertson phenomenon, or complete loss of the light reflex with
preservation of contraction on voluntary^ accommodation. The light
reflex should be tested not only by direct illumination of each pupil in
turn, but also by the consensual method, which is performed by holding
open the lid of one eye and watching the pupil of that eye attentively,
whilst with the other hand the other eye is alternately opened and
closed. This applies a feebler stimulus to the eye under observation,
and loss of this indirect or consensual reflex is often observed in the
early stage of the Argyll-Robertson pupil when the direct reflex is
still preserved. Either exaggeration or loss of knee-jerks may occur
in early general paral5."sis. Exaggeration of deep reflexes occurs in too
many other conditions to be pathognomonic by itself. Loss of the
knee-jerks, and still more so, loss of the ankle-jerks, is highly suggestive
of tabo-paralysis.

Articnlation should also be tested by asking the patient to repeat
catch-phrases, such as " hopping hippopotamus ” or British Constitu-
tion,” several times in rapid succession. The general paralytic may
either repeat a sydlable several times over, or he may slur the syllables
together. The face loses its normal play of expression comparatively
early, even before the occurrence of facial or lingual tremors.

If some, but not necessarily all, of the foregoing physical signs be
present, and associated with mental symptoms, such as failing memory,
impaired judgment, or moral laxity, and especially if these occur in a
man of middle age who has had syphilis ten or fifteen years previously,
general paralysis should be suspected, and the blood-serum and cerebro-
spinal fluid submitted to laboratory' tests forthwith.

First, about 5 c.c. of blood withdrawn by^ venepuncture should be
examined for the Wassermann reaction. In 99 per cent of cases of
general paral3^sis this reaction is positive. A negative reaction there-
fore almost certainly excludes general paralysis. If any doubt still
exists, the cerebrospinal fluid should be similarly^ examined. A nega-
tive Wassermann reaction in this wdll exclude general paralysis, in
spite of the clinical symptoms. Should the blood yield a positive
Wassermann reaction, this means that latent syphilis is present, and
lumbar puncture should always be performed. If the reaction in the
fluid then proves to be negative, the case is probably not one of general
paralysis but of mental symptoms in a syphilitic patient, possibly due
to cerebral syphilis. If the reaction be positive in the spinal fluid as
well as in the blood, there are three possibilities ; (i) General paralysis,
the most probable ; (2) Tabes with mental symptoms ; (3) Cerebro-

SYPHILIS, CEREBROSPINAL 588 MEDICAL ANNUAL

spinal syphilis with mental symptoms. A positive reaction in the
cerebrospinal fluid is a paramount sign, pointing to one of the foregoing
tl]ree diseases.

Tlie next step is a cytological examination of the spinal fluid.
Lymphocytosis occurs in general paralysis, tabes, and cerebrospinal
syphilis. In these diseases we also find an excess of globulin by the
Nonne-Apelt test, also an excess of over o*i per cent of albumin by
Aufrecht's albuminimeter. The presence of plasma-cells in the cell
count is highly suggestive of general paralysis.

How are we to distinguish between tabo-paralysis and a case of tabes
with mental symptoms not due to general paralysis ? This is some-
times a matter of considerable difficulty. The signs of mental weak-
ness and loss of memory in which the deterioration is progressive, are
specially suspicious of general paralysis, more particularly if articula-
tory difficulties are also present. Cerebrospinal syphilis with mental
symptoms may simulate general paralysis so closely as to make a
differential diagnosis impossible during life. Most of the supposed
recoveries from general paralysis, as Robertson points out, have really
been cases of cerebral syphilis. The mental symptoms do not help
materially in distinguishing the two conditions, and more weight must
be placed on the physical signs. These are more definitely localized in
cerebral syphilis ; also they appear more suddenly and are more perma-
nent than similar signs in general paralysis. Lastl^L antisyphilitic
treatment by mercury, iodide, or salvarsan, usually benefits cerebral
syphilis, but is unavailing in general paralysis.

This remarkable failure of the most energetic anti syphilitic remedies
led many workers to the hypothesis that general paralysis was not a
true s^T'philitic disease, but a so-called meta- or para-syphilitic malady,
due not to the spirochaete itself but to some other poison to which the
syphilitic organisms predisposed the patient. To this theory the
almost invariable positive result of the Wassermann reaction in the
blood and cerebrospinal fluid was always an objection, and both v.
Wassermann and Ehrlich maintained that the spirochaste must still be
present in the nervous system, although they themselves had not been
fortunate enough to discover it. The final link in the chain of evidence
was furnished, in the end of 1912 by Noguchi, ^ w^ho demonstrated the
existence of spirochaetes in the cerebral cortex of about 20 per cent of
general paralytics examined by him. This epoch-making observation,
which definitely classes general paralysis as a true syphilitic disease,
renders still more remarkable its absolute intractability and resistance
to all ordinary antisyphilitic remedies. Ehrlich^ suggests as a possible
explanation that in general paralysis, which, as is well known, develops
many years after the original infection, there is a strain of surviving
spirochaetes with special biological peculiarities widely different from
those of the organisms which produced the original disease, and that
together with this biological difference, there is a special resistance to
therapeutic agents. It is also possible, as suggested by Westphal,^
that as a result of special conditions of nutrition and circulation in the

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589 SYPHILIS, CEREBROSPINAL

brain, therapeutic agents cannot reach the surviving spirochaetes in
sufficient quantity or with sufficient intensity to destroy them. He
points out that the spirochaetes in the general-paratytic brain are
singularly scattered in the deeper layers of the cortex, burrowing among
the nerve-cells, and that, as a rule, they are at some distance from the
vessels. Sioli has made the attractive suggestion that the meninges
and adventitial vascular coats, in the general-paralytic brain, form a
wall of resistance to infiltration-cells, and that it is this diminished
meningeal permeability which prevents the ordinary antis3^philitic
remedies from reaching the spirochaetes. The practical conclusion, as
regards antisyphilitic treatment of genei*al paralysis, would be either
to increase the permeability of the meninges, or to search for some
more permeable remedy, either amongst the arsenical group, as Ehrlich
suggests, or elsewhere. Noguchi^ has also succeeded in producing
typical syphilitic sclerosis in the rabbit's testicle by inoculation with a
fresh brain emulsion from a case of general paralysis. ‘ In any case,
Noguchi's observations on the brain encourage us to persevere with
fresh attempts in the treatment of this disease, now that w^e know it to
be not merely a sequela but an active syphilitic malady. But before
accepting any remedy as efficient, we must bear in mind the fact
that spontaneous remissions are not uncommon in genei'al paralysis,
so that prolonged and carefully controlled observations will yet be
necessary before it can be claimed that general paral3?'sis is actually
curable.

Treatment. — Have recoveries ever taken place ? No satisfactory
answer can yet be given to this question. It is well known that remis-
sions not infrequently occur in this disease, their duration varying
from six to twelve months, and in rare cases lasting four or five years.
Such remissions may occur spontaneously. They may also be associ-
ated with the repeated production of artificial p^^rexia, whether by
injection of Tuberculin (Wagner), or of Sodium Nucleinate (Donath).
(See Medical Annual, 1913.)

George Robertson devised the following treatment, which aims
at introducing into the cerebrospinal fluid a serum highh^ charged with
s^^^philitic antibodies. An intravenous injection of Salvarsan in
moderate amount (o'3 to o-6 gram for an average man) was given at
intervals of about a month. In the intervals between the salvarsan
injections antisyphilitic serum was injected intrathecalljL a correspond-
ing quantity of cerebrospinal fluid being previously withdrawn. The
serum was prepared as follows : A patient suffering from secondary
syphilis was given a full intravenous dose of salvarsan. Three days
later, when the blood was presumably full of syphilitic antibodies,
20 or 30 c.c. of blood were withdrawn aseptically by venepuncture.
This was allowed to clot, and the clotted blood was left on ice for about
twenty-four hours whilst cultures were made from the serum to ensure
its sterility. If sterile, it was gently poured into a sterile flask with
other antis3?'philitic sera. From 10 to 15 c.c. of this mixed serum,
twenty-four or forty-eight hours old, was used for injection. In other

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cases serum was obtained from the general paralytic patient’s own
blood, an hour after he had received an intravenous injection of salvar-
san. The serum was collected and treated as above, but was injected
before the serum was twenty-four hours old, and in smaller doses,
3 or 4 c.c. Whilst the patient was undergoing this treatment, he
received full doses of urotropin (10 gr. thrice daily), since this drug is
known to be excreted into the cerebrospinal fluid, and, even by itself,
has been reported to produce improvement in general paralysis.

The results of this treatment, as recorded by Kobertson, are admitted
to be inconclusive- In all he treated twelve cases, and states that
seldom did it happen that a patient did not show some slight improve-
ment in his symptoms after the first or second injection. Five cases
showed considerable excitement, followed by definite improvement.
Three cases recovered sufficiently to be discharged from the asylum.
Of these three, one relapsed in six months, another several months
after discharge met with a fatal accident at home, while the third has
remained well for a year. In none of these cases did the Wassermann
reaction in the spinal fluid become negative, although some showed
temporary diminution in its intensity. In one-fourth of the cases
there was marked diminution of the lymphocytosis, and in another
fourth it was slight and transient. Roughly speaking, this means that
in one half of these cases there was evidence of improvement in the
cerebrospinal fluid. Robertson himself points out that the foregoing
results are insufficient to show’ whether w’e have to do w’ith mere
remissions or w’ith an actual curative process. He inclines to the
opinion that the treatment w’as not vigorous enough, either as regards
the amount of salvarsan administered, the number of the injections,
or the rapidity with w’hich these succeeded one another.

At the recent International Congress in London in 1913, during a
discussion upon the parasyphilitic ” diseases, tabes and general
paralysis, the present unsatisfactory position of therapeutics of these
diseases was referred to by numerous speakers. Despite the undoubted
fact that both tabes and general paralysis are syphilitic in origin, the
fact remains that ordinary antisyphilitic treatment, whether b}^
mercury, iodide of potassium, or salvarsan, has little or no effect. It
has been suggested that the reason for this may be that mercury and
salvarsan cannot pass through the choroid plexus into the cerebro-
spinal fluid, so as to exercise their effects upon the nerve tissues bathed
in that fluid. The injection of mercurial or arsenical preparations
directly into the cerebrospinal pond through a lumbar-puncture needle
w^ould be highly dangerous, inasmuch as the drug so injected, in order
to kill the spirochaste, w’ould at the same time prove fatal to the patient.
The ideal treatment, therefore, is one wffiich wall either diffuse through
the choroid plexus when introduced into the general circulation, or one
which can be directly injected into the cerebrospinal canal.

In this connection an interesting communication was made at the
Congress by Swift, from the Rockefeller Institute in New York. The
method of treatment, broadly speaking, is similar to that of Robertson.

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The patient is given an ordinary dose of salvarsan or of neosalvarsan
intravenously. An hour later, when the drug is already well diffused
through the system, a quantity of blood is withdrawn by venesection.
This blood is centrifuged, in order to get rid of all cellular elements,
since red corpuscles, if introduced into the cerebrospinal fluid, merely
undergo haemolysis, and may produce deleterious effects. The serum
is then diluted to a 40 per cent mixture by the addition of normal
saline solution. The mixture is heated at a temperature of 56"^ C, for
half an hour. This not only renders it sterile, but increases its bacteri-
cidal effect. Next day a lumbar puncture is performed, and the cerebro-
spinal fluid is allowed to escape until its pressure falls to 30 mm. of
cerebrospinal fluid. A 30-c.c. glass syringe is then attached to the
lumbar-puncture needle by means of a piece of sterilized rubber tubing
40 cm. in length. The diluted serum is now allow^ed to flo^v into the
cerebrospinal canal by gravity, not by pressure ; 30 c.c. or more of the
mixture are injected. This process is repeated about every two weeks.
Sometimes a reaction is observed, consisting in some local pain with
slight fever, but this is inconstant. In most cases the patient's own
serum is used for injection, but sometimes the serum of other patients
treated b}^ salvarsan is employed.

Swift related the results of thirty- two tabetic cases thus treated. In
four the cerebrospinal fluid became normal, having lost its cells, its
globulin, and its Wassermann reaction. In 40 per cent of cases the
Wassermann reaction in the cerebrospinal fluid became negative. In*
30 per cent more the reaction diminished in intensity, whilst in three
patients, i.e. 10 per cent, it was unchanged. The clinical results
were not detailed by Swift.

Salvapsaxi, — ^The most brilliant results of salvarsan medication are
undoubtedly its effects upon the various syphilitic affections of skin,
mucous membranes, and periosteal and bony structures. Compared with
these, its results in syphilitic and parasyphilitic diseases of the nervous
system are less satisfactory, probably because we have to deal with
highly differentiated and delicate tissues which are not only easily
and permanently damaged, but in which regeneration is usually
impossible and compensating processes occur with much less readiness
than in simpler and less specialized tissues.

Straightforward cerebyal or spinal syphilis, if treated promptly and
thoroughly with salvarsan, is usually beneficially influenced. Thus
Donath® records forty-eight cases, including hemiplegia, fits, headache,
cranial nerve paralyses, paraplegia, bladder troubles, etc. In only one
case of his foregoing series was a mercurial cure superadded. Most
neurologists, how^ever, find by experience that the effects of salvarsan
treatment are enhanced by Mercurial treatment, and the writer is in
the habit of giving full doses of mercury, either in the form of per-
chloride by the mouth, or in severe cases by energetic inunction. It
is also a prudent precaution to administer salvarsan in small doses of
0*3 gram intravenously at frequent intervals, rather than in the full
dose of o'6 gram at a single sitting. The results of this treatment are

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to bring the active syphilitic process to a close, and to permit of the
recovery of such nerve-cells and fibres as have not actually been
destroyed. It is futile to hope for the cure, say, of a hemiplegia due
to an area of softening resulting from the thrombosis of a syphilitic
artery. We may remove the gummatous infiltration of the arterial
wall, but the secondary thrombotic area of destroyed nerve-tissues
remains, permanently damaged.

With regard to tabes and general paralysis the results of salvarsan
treatment are different in the two diseases.

In tabes, especially if the patient comes under treatment in the early
stages of the disease, his symptoms are often ameliorated to a remark-
able degree by salvarsan treatment. The lightning-pains are specially
benefited, and similar results can also be observed after treatment by
Enesol, another arsenical salt allied to salvarsan. It has the advantage
of being suitable for hypodermic administration, and it is therefore
worth bearing in mind, in cases ^vhere intravenous medication by
salvarsan is, for some reason or other, impracticable. Donath records
thirty-one cases of tabes treated by salvarsan, apparently, so far as he
gives details, by a single dose in each case. Most of them were in the
early stages of the disease. Lightning-pains w^ere relieved in seven
cases, although in one there was a transient exacerbation of pain for
two days after the injection, follo^ved by complete relief. Ataxia
disappeared in two cases, but became aggravated in a third. Cranial
nerve palsies cleared up in two cases. Sphincter troubles also improved
in two or three instances. Gastric crises disappeared in two patients.
The general nutrition improved in nineteen patients, of whom six
showed specially marked improvement and increased in weight. The
Wassermann reaction in the blood was estimated in seventeen cases,
of which five were negative and eleven positive. In only one case did
the reaction become negative under treatment.

In general paralysis Donath records twenty-eight cases treated by
.salvarsan, generally in two doses, sometimes combined with seven ox-
eight injections of Sodium Hucleinate (see Medical Annual, 1913,^. 192),
and claims to have observed improvement of mental power in nine
cases, whilst the general nutrition improved in eighteen. In three cases
the pupillary reflex returned, and in eleven the articulation improved.
Three patients recovered sufficiently to resume their work. Whether
these three cases are to be regarded as cures or simply remissions, time
alone can show.

Nerve-Relapses (“ Neuro-Recidive after Salvarsan
Treatment.

Amongst the incidents of the salvarsan treatment of syphilis, one of
the most interesting is the occasional occurrence of symptoms indi-
cating a focal lesion in the central nervous system, even in patients who
previously had shown no obvious symptoms of nervous syphilis.
These so-called neuro-recidive,’* or nerve-relapses, occur almost
exclusively in cases where salvarsan has been administered for primary

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SYPHILIS, CEREBROSPINAL

or secondary syphilis. The a\^rage time of onset of nerve -relapses is
from five to eight weeks after the last sah^arsan injection.

Various theories have been suggested to explain the origin of such
nerve-relapses. Thus, for example, some have attributed the pheno-
mena to a neurotropic toxic action of salvarsan itself ; others have
suggested that it induces vascular changes, affording a locus minovis
resisteniic? to the siir\'iviiig spirochcetes. Both these hypotheses,
hov'ever, are negatived by the fact that salvarsan exercises a striking
curative effect in nerve-relapses. Others, again, suggest that salvarsan,
whilst killing the main body of spirochaetes in the general circulation,
has greater difficulty in reaching certain small foci harboured in parts
of the nervous system, and that it may even provoke these survivors
to special activity. Others, again, in view of the irregularity of occur-
rence of such cases in some cliniques and of their relative infre-
quency in others, have suggested that the technique of the salvarsan
injections may have something to do with it. Thus Cronquist' is of
opinion that the readiness with which salvarsan becomes oxidized
may be a factor in increasing its toxicity, especially if the solution
be not injected forthwith, but is allowed to stand for some little time.
Ehrlich, it vdll be remembered, instructs the physician to inject the
salvarsan solution freshly made. In many cliniques, however, a large
quantity of solution is made up at once, and this is divided amongst
the various patients who may require salvarsan treatment in the
course of one seance. Supposing that at such a clinique twelve patients
be injected successively at intervals of about five minutes, it is evident
that the solution administered to the twelfth patient may easily become
appreciably oxidized. Cronquist, therefore, insists upon the advisa-
bility of making up the solution separately for each patient from his
own ampoule and injecting it forthwith. Under these conditions he
only observed one nerve-relapse, and that a mild one, consisting in
transient facial palsy with diplopia, out of 150 injections in eighty
patients.

The parts of the nervous system most commonly affected are certain
cranial nerves, especially the auditory, facial, and optic nerves,
although less commonly, lesions may also occur elsewhere in the
central or peripheral nervous system, producing convulsions (local or
general) , headache, vomiting, giddiness, etc. This special vulnerability
of the auditory nerves should be carefully borne in mind, since not
infrequently the otologist detect failure of hearing long before
the patient notices any subj ective auditory abnormality. The auditory
nerve, as Dreyfus® points out, is not only the nerve most commonly
attacked, but also the most sensitive to the syphilitic poison.

Another point which has become evident to neurologists during the
study of such cases is that these nerve-relapses are really syphilitic in
nature. Practically all of them, on examination of the cerebrospinal
fluid, show the characteristic pleocytosis, together with the excess of
globulin, of a syphilitic meningitis, whilst the Wassermann reaction is
usually positive, both in the blood and cerebrospinal fluid, Nichols

SYPHILIS, CEREBROSPINAL 504 MJvDTCAL ANNUAL

and Hough'’ have demonstrated the presence of spiroch£etes in the
cerebrospinal thiid by inoculation into the testicle of the rabbit. The
Wassermann reaction in the blood may become negative under treat-
ment long before the nei'vous symptoms clear up, whilst the cerebro-
spinal fluid still shows signs of active syphilitic changes. Hence the
importance of examining the cerebrospinal fluid repeatedly in cases of
suspected nerve-relapses, and also during the course of their treatment.
An abundant pleoc3^tosis not only clinches the diagnosis of cerebro-
spinal syphilis, but calls for energetic antisyphilitic treatment. As the
nerve-relapse clears up, so does the pleocytosis diminish, and so long
as a definite pleocytosis remains, there is need for further treatment
and prospect of improvement.

Regarding nerve-relapses, therefore, simply as varieties of cerebro-
spinal syphilis which have arisen under special circumstances, their
treatment consists in a combination of Salvarsan with Mercury,
controlled by repeated observations on the cerebrospinal fluid. The
salvarsan should be administered in small doses at short intervals,
whilst the mercury should be pushed to its full extent. The writer
gives doses of 0-3 gram of salvarsan, or 0*45 gram neosalvarsan, intra-
venously, once or twice a week, together with inunction by a mercurial
cream. The patient must not be considered cured until the Wasser-
mann reaction in the blood is constantly negative and the cerebro-
spinal fluid is also normal. There is, of course, a limit to which salvar-
san can be safely pushed : Dre^dus holds that a total of 4 to 5 grams
within a period of five to -six weeks is about the maximum safe
amount. If more be given, there is a risk of arsenical neuritis.
Should the cerebrospinal fluid still show signs of abnormality at the
end of such a course, it is prudent to drop the salvarsan for a month
and then start again, persevering in the meantime with energetic
mercurial inunction, A striking fact in these cases is the improvement
in the patient’s general health during the course of “ intensive ”
treatment.

A sharp distinction must be drawn between the syphilitic nerve -
relapses following salvarsan treatment and another group of cases of
true salvarsan poisoning. The clinical picture of this latter condition
is entire!}^ different, as will be seen by the following case recorded by
Assmann.^o

A man of 30 was admitted with a primary" sore, in which spirocliEetes were
demonstrated, and with hard bubos but no cutaneous rash. Salvarsan
0-6 gram was given intravenous^, together with an intramuscular injection
of 0*1 gram of salic^date of mercury. The patient had mild p^wexia in the
afternoon, but no headache or vomiting. For the next two da^^s he felt quite
well, with normal temperature. On the third day after the original injection,
he received a second dose of salvarsan, o-6 gram, together with an intra-
muscular injection of salicylate of mercury as before. The same afternoon
he had fever, nausea, and headache. These sjmiptoms persisted, and on the
third day after the second salvarsan injection, he developed severe epilepti-
form fits and mental dullness, the fits recurring at intervals of half an hour.
The optic discs, sensory, motor, and reflex phenomena were all normal. The
cerebrospinal fluid contained onh’ 7 to 8 lyinphocj^tes per c.mm., but showed

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excess of globulin. The Wasseruiann reaction was negative in the cerebro-
spinal fluid, but positive in the blood. The urine was highly albuminous,
with a few red cells in the deposit. Despite full doses of chloral the tempera-
ture continued to rise. The patient died comatose, thirty-six hours after the
onset of the head symptoms, i.e., five days after his second salvarsan injection.
The cerebrospinal fluid withdrawn immediate^ after death was slightly
turbid, and contained 130 cells per c.mm., of which 90 per cent were poly-
nuclears, 2 per cent small Ij^mphocytes, and 8 per cent large Ij^mphocytes.
The Wassermann reaction in the fluid was absolutely negative. There" was
distinct cloudy swelling of the kidnej’s and liver, no gastric or intestinal abnor-
mality, and no jaundice. All the other organs were normal save the brain,
in which there were abundant perivascular capillary hemorrhages, irregularly
distributed in the grey and white matter. Here and there, near the cortex,
there 'were also perivascular infiltrations of polynuclear cells, also around the
margin of the large hsemorrhages.

The foregoing description differs in several important details from
the common clinical picture af a nerve-relapse. First, the cerebro-
spinal fluid was at first practically normal as regards cell-count, save
for a slight and insignificant increase of lymphocytes, amounting only
to 7 to 8 per c.mm. ; later a marked pleocytosis occurred, but, unlike
the cases of nerve-relapse, this was of a polynuclear variety. There was
progressive increase of albumin, and especially of globulin, from the
first. These characters are against the syphilitic origin of the changes
in the fluid, and, moreover, the Wassermann reaction was negative
throughout. We therefore conclude that the changes in the fluid were
not syphilitic, but due to acute poisoning, probably arsenical in nature,
as evidenced by the changes in the kidneys. It may be incidentally
remarked that gastro-intestinal symptoms, which are so constantly
present in ordinary arsenical poisoning, where the poison is taken by
the mouth, were here conspicuous by their absence. Another point of
interest is the fact that there was a free interval of two or three days,
during which the patient had no symptoms, before the signs of salvar-
san poisoning set in. Lastly, although this is a point on which Assmann
lays no stress, but which appears to be of considerable practical import-
ance, the amount of salvarsan injected was its full dose of o*6 gram on
two successive occasions, at intervals of three days. This should teach
us caution in the administration of so potent a drug.

.References. — ^Edin. Med. Jour. 1913, i, 293 and 42S ; ^Jour. Expev. Med.
1913, Feb.; ^Miinch. med. Woch. 1913, 443 1 '^Berl. klin. Woch, 1913, 669;
^Joiir. Amer. Med. Assoc. 1913, i, 85; ^Mihich. med. Woch, 1912, 2276 and
2342; '^Ibid. 2449; Hhid. 2238 and 22S7 ; ^Jour. Amer. Med. Assoc. 1913,
i, 108; ^^Berl. klin. Woch. 1912, 234G and 2414.

Bedford Pierce, M.D., F.R.C.P.

General Paralysis . — The discovery hy Noguchi of the SpirochcBta
pallida in the brains of fourteen general paralytics is a matter of great
importance. Although the micro-organism has not been found in every
case examined, there can now^ be no doubt as to the true nature of this
disease. The assumption of a paras5^philitic disease is no longer
required. This discovery was no doubt largely foreshadowed when it
was found that the cerebrospinal fluid and the blood of general paralytics
reacted positively to the Wassermann test, but the finding of the

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MEDICAL ANNUAL

spiroclia^te in the coi'tex of the brain puts an end to controversy. The
cause of general paralysis has been discovered. There is, however,
still room for doubt whether the spirochaete in question is identical
with that producing syphilis. The fact that general paralytics rarely
shows marlcs of tertiary syphilis, and that even when there is a history
the initial ‘symptoms are often peculiaily mild, and further, the ineffi-
cacy of antisyphilitic treatment to prevent the development of general
paralysis, lea\^es room for querying whether there may not be varieties
of spirochsetes, one specially attacking skin or connective tissues and
another with special affinity for nervous structures. It is interesting
to note that the spirochsetes are found in the grey matter of the
convolutions, lying amongst the nerve cells, and they are rarely seen in
the white matter or in the pia-arachnoid.

G. M. Robertson’^ discusses the problem of general paralysis at
length : its symptoms, its early diagnosis, its etiology, and particularly
its treatment. Five methods of treatment were adopted : (i) Intra-
venous injection of Salvarsan; (2) Intraspinal injection of Antisyphilitic
Serum; Intraspinal injections of Salvarsan Serum; (4) Urotropin;
(5) Calomel. In all cases the results were disappointing, although in
some there was a decrease in the l3miphoc5?’tosis and a diminution ot
intensit}^ of the Wassermann reaction.

Barton White^ made an exhaustive examination of the urine of ten
cases of general paral3\sis before and after the administration of hexa-
meth^denetetramine (Urotropin). In all these cases, before treatment,
micro-organisms were found, viz., B. coll in three, a diphtheroid in four,
a staphylococcus in five, a streptococcus in two, and a diplococcus in one.
The drug was given for varying periods from two to ten \veeks, and in
evei'}^ case except that with the diplococcus the urine was found to be
sterile at the second test and remained so for several days. Treatment
with specially?' pi’epared vaccines was not encouraging. The opinion
was expressed that the routine treatnient of several paralytics by
hexamethylenetetramine Avas justified, and that in consequence there
were fewer seizures, the course was prolonged, and the difficulties of
nursing w^ere reduced. Collins stated that he had found urotropin
produced incontinence. Soutar said that clinically he had found
urotropin of value.

Mental Deficiency and Syphilis . — Kate Fraser^ summarized the
results of investigations, by means of the Wassermann reaction, as to
the frequency with which, S3fphilis is found associated with mental
disease and epilepS3\ .These results varied from 1*5 to 30 per cent.
Thomson and his co-workers examined by the original method
upwards of 2000 cases of mental deficiency, and found that only 31 gave
a positive reaction, and only one among 25 cases of epilepsy. In
contrast to this, Raviart and others examined 246 idiots, and found that
30 per cent reacted. Of her own cases, 99 in number, 10 were epileptic
without decided mental defect. Of the 8g defectives, 40 gave a positive
reaction and ii were doubtful. Of the 10 sane epileptics, 4 gave a
positive reaction. Members of the family were investigated in 13 cases

PL A TE LX I.

ECZEMA ORIS SYPHILITICA

J'ain^ui^ hi ntUy furnished by Dr, Lionard I''i/idiay.

MDDICAL A ANNUAL,

PLATE LXII.

ECZEMA ORIS SYPHILITICA

From Photographs kindly furnished by Dr. Leonard Findlay

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597

SYPHILIS, CONGENITAL

where the child gave a negative result, and a positive reaction was
obtained in 8 instances. If these cases are included, the Wassermann
reaction showed that 57*7 per cent had been infected with syphilis.
Stigmata of syphilis were found in only 8 of the positive cases. It was
noteworthy that of 23 normal children taken as controls, 2 gave a
positive result, 19 were negative, and 2 doubtful.

References. — ^Jour. Ment. Sci. 1913, Apr. ; ^Jbid. Oct. ; ^Ibid.

SYPHILIS, CONGENITAL, {See also Syphilis.)

Frederick Langmead, M.D., F.R,C.P*

Leonard Findlay and H. Ferguson Watson^ add yet another condi-
tion to the many which are ascribed to congenital syphilis. They,
designate it “ eczema oris syphilitica (Plates LXl, LX II), In its
most typical form the lesion is situated at one or both angles of the
mouth, and radiates therefrom towards the cheek, sometimes in the
form of fan-shaped patches. It may, however, completely surround
the mouth and implicate the face extensively. The patches are
somewhat irregular in shape, with sharply-cut or ill-defined margins.
These are red in colour, the hypersemia at times being very marked.
The surface is, as a rule, dry and scaly, although occasionally,
especially during exacerbations, there may be some discharge, with
the formation of crusts, and at this period there is always a certain
degree of induration. The eczematous patch is continuous with, and
frequently invades, the mucous membrane of the lip, giving a slightly
papillary appearance. The lips themselves may be swollen to a greater
or less degree. A similar condition around the nostrils (where there
is usually a greater tendency to moisture), and eczema tarsi are
also present in a proportion of the cases. It is a most obstinate and
chronic malad}^ varying much in severity from time to time. Of the
patients, twenty-one in all, only five manifested .specific stigmata. All
but two reacted positivel}^ to the Wassermann test, while the blood
of the mothers of these two gave a positive result. The appearance
of the lesion was sufficiently characteristic to permit a diagnosis on
purely clinical grounds.

Most English observers regard cranioiabes as due to congenital
syphilis, but Leroux and Labbe,^ from an examination of thirty-two
cases, come to the conclusion that it is an osseous dystrophy due to
multiple causes, congenital syphilis being the most important. In
the 32 cases examined, syphilis was found in 17, tuberculosis in 5,
parental alcoholism in 2, other inherited states in 3, whilst the cause
was obscure in 5. The authors remark that craniotabes generally
occurs in infants affected by inherited dystrophic conditions, whose
nutrition has suffered in utero, and who are usually born prematurely
or in an enfeebled condition.

The influence of syphilis on infant mortality and the future of the
race continues to attract attention. Thus Mott® states that a large
number of infants exist who, though apparently healthy, arc really
infected, and should be treated to prevent them from suffering from the

SYPHILIS, CONGENITAL 598 MEDICAL ANNUAL

disease later in life. According to him, all mothers of congenital
syphilitic children give a positive Wassermann reaction, and thus by
this reaction we ha\'e not only a means of ascertaining whether the
apparently healthy but suspected infant should be treated to prevent
it from developing serious disease, but also examination of the blood
of the suspect but apparently healthy mother will enable treatment
to be applied to her which will permit of the birth of healthy uninfected
children.

Amentia would appear to bear a closer relation to congenital syphilis
than has been acknowledged hitherto. Thus \V. C. Stoner and E. L.
Keiser^ applied the Wassermann reaction to 1050 unselected cases of
all grades of mental deficiency, and found it positive in 7*9 per cent ;
Lippmaiin''^ in 78 cases obtained a positive reaction in 9 per cent ;
Dean^ in 330 idiots in 15-4 per cent; and Eaviart, Breton, Petit,
Gayet, and Cannae," in 246 cases, in more than 30 per cent.

It must be remembered, however, that investigators are still actively
engaged in testing the validity af the Wassermann reaction as a means
of diagnosis of congenital syphilis. Thus F. S. Churchill® employed
the reaction in 102 children, aged from three days to twelve years,
admitted to hospital for various diseases other than syphilis. A posi-
tive result was obtained in 39 cases ; 24 of these showed suggestive
physical signs ; in 5 there w^as a suggestive family history or positive
personal record ; and in 10 there was neither family history, personal
history, nor physical signs suggestive of the disorder. This author
admits that some of these may have been the subjects of syphilis
hereditaria tarda, but in 3 fatal cases in this group there was no
gross or microscopic evidence of syphilis post mortem. E. Andronesco
and P. Saratzeano^ tested 22 syphilitic children and 13 mothers by
Wassermann ’s original method. They conclude that : (i) Colles s
law is quite correct ; (2) Mothers of syphilitic children give as

positive a Wassermann reaction as cases of fiorid syphilis ; (3)

The number of births has no influence upon the reaction ; (4) The
reaction is more intense in congenital syphilitic children than in their
mothers who are free from visible lesions. D, Caffarena^® tested the
reaction in 20 rickety children, and found it positive in 6. This
observation cannot be said to argue against the value of the test, for
it opens up the question of the relationship of rickets to congenital
syphilis. {See also Syphilis, Cerebrospinal.)

Treatment. — ^The work of W. P. Lucas^^ throws further doubt on
the efficiency of our treatment. He traced 59 cases which had
received hospital treatment. These he divided into three groups :
(i) Those who apparently were mentally normal ; (2) Those who were
mentally backward ; and {3) Those who had died. There ’were ig
in the first group ; of these, 5 were of school age, ranging from six to
sixteen years ; 10 were between two and six years ; and 4 were under
two. The mentally backward also numbered 19, of whom ii were of
school age, and 8 were betw’een two and six years old. Twenty-one
had died. He attributes the high mortality and percentage of back-

NEW TREATMENT

599

TETANUS

ward children to the lack of more systematic following-up of the
treatment. Many of the infants were not brought for treatment after
the rash had disappeared.

Salvarsan, as a remedial measure, is still on its trial. L, E. La
Fetra’s^^ results are favourable to it. He has. treated a series of
25 cases of congenital syphilis in children, aged from six weeks to
two years old. Ten received salvarsan with or without mercury,
and 15 were treated with mercur}’ alone. Of the former, only 2 died ;
all the rest showed marked gain in weight and improvement in the
general condition. Of the latter, 3 improved, 2 remained stationary,
and 10 died. He recommends a dose of not less than o*o6 gram per
kilo. of the body weight. L. Maccone^^ records 10 cases treated by
salvarsan. The children’s ages varied from eighteen months to tweh^e
years : 5 recovered, 4 showed some improvement, and in only i was
the condition uninfluenced. Of 9 who showed a positive 'Wassermann
reaction before treatment, 8 lost it. He thinks that 606 ” is an
efficient reined}^ in the secondary generalized forms of congenital syphilis.
In the tertiary localized forms it is less active, whilst in the later
stages, including the dystrophic forms, its action is nil. Weil, Morel,
and Mouriquand^^ were led by the difficulties of intravenous injection
in 3"Oung children to administer the drug per rectum. Five to 10 drops
of laudanum were added to the solution to ensure rectal tolerance.
The authors found that the drug was easily absorbed by the mucous
membrane, and that definite amelioration of the symptoms was pro-
duced. No local or general reaction occurred, an observation which
led these authors to prefer the rectal route for the administration of
salvarsan in children.

References.- — ^Lancet, 1913, i, S75 ; “Ann. de 21 ed. et Chir. Inf. 1612,
xvi, 4S1 {Byii. Jour. Child. Dis. 1913, 44); ^English-speaking Conf, on
Infant Mortality ; ^Cleveland Med. Jour. 1912, x, 251 {Brit. Jour. Child.
Dis. 1912, 514) ; ^Brit. Jour. Child. Dis. 1912, 388 ; ^Ibid. 3S5 ; "Ibid.
3SS ; ^Anier. Jour. Dis. Child. 1912, 362 {Brit. Jour. Child. Dis. 1913. 44) ;

^Presse Med. 1912, xx, 271 {Brit. Jour. Child, Dis. 1913. 45) ; d,

Osped. xxxiii, 642 {Brit, Jour. Child. Dis. 1913, 45) ; 2 Jccl. and

Surg. Jour. 1912, ii, 27S ; '^Klfch. of Pcd. 1912, 654 {Brit. Jour. Child. Dis.

1913, 45) ; ^^Gas. Internal, d. Med., Chir., etc. 1912, 652, 727, 77G [Brit. Jour.
Child. Dis. 1913, 45) ; ^'^Lyon Med, 1912, cxix, 45 {Brit. Jour. Child. Dis.

1913. 46)-

TABES DORSALIS. [See Syphilis, Cerebrospinal.)

TESTIS, INFLAMMATION OF. {See Orchitis.)

TETANUS. Purves Stewart, M.D., F.R.C.P.

Treatment. — Three ^^ears ago, in the Medical Annual, the writer
gave a resume of various modern methods. Of these remedies the
chief are antitetanus serum, carbolic acid, and magnesium sulphate.
Baccelli’s results by the carbolic-acid treatment -were discussed in the
]\Iedical Annual for 1912, and it now seems an opportune time to
describe somewhat more in detail the chief facts of interest in connection
with the treatment by Magnesium Sulphate.

TETANUS

600

MEDICAL ANNUAL

Before the introduction of anti-tetanus serum Ehrlich in 1890,
the mortality in cases of tetanus, according to v. Leyden, was from
80 to 90 per cent, some authors placing it as high as 93 per cent. The
introduction of serum-therapy reduced this mortality to a considerable
extent, some observei's placing it as low as 28 per cent (Engelmann),
others as high as 55 per cent (Arndt). By the carbolic-acid treatment
without anti-tetanus serum Baccelli claims to have reduced the
mortality to 17*4 per cent in a series of 190 unselected cases. Dutoit,i
with a much smaller number of cases collected from various sources
and treated by magnesium sulphate, finds that 7 out of 22 ^vere fatal,
i.e., a percentage of 22-7 per cent deaths.

Meltzer and Auer, working in the Rockefeller Institute, have con-
ducted numerous experiments upon the effect of magnesium salts.
They found that when solutions of magnesium sulphate or magnesium
chloride are injected hypodermically in an animal in the proportion
of 1*5 parts per 1000 of its body weight, the result is a deep sleep, wdth
complete anaesthesia and total relaxation of the voluntary muscles,
and loss of deep reflexes. If the above dose be not exceeded, the
animals recover after a certain time. If the dose be too high (over
2 parts per 1000) death occurs from respiratory paralysis, the heart’s
action being preserved for a time after the breathing has ceased.
The same observers studied the effects of intravenous injections of
magnesium sulphate, and pointed out that the respiratory paralysis
which was produced could be successful!}^ treated by artificial respira-
tion, wlijlst meantime cardiac action and blood-pressure remained
unchanged. On intravenous injection of a 25 per cent solution of the
drug, they produced anaesthesia without any initial stage of irritation,
and observed that sensory functions ivere paralyzed before motor.
The symptoms thus produced could be washed out, as it were, after a
certain time, by means of transfusion with normal saline or with Ringer’s
serum. Thirdly, they tried the effect of inlraihccal injection of mag-
nesium sulphate solution, and found that sensory and flaccid motor
paralysis set in within two minutes, especially affecting the low'er limbs
and trunk, and gradually spreading upwards. The conjunctival
reflexes, as before, together with the cardiac activity and the blood-
pressure, remained iindiminished. Meanwhile respiration became
markedly slowed and inefficient. The sensory and motor paralysis
lasted several hours.

Reasoning from the foregoing experiments (performed chief! 3^ on
monke3^s) to the human subject, Kocher estimated the therapeutic
intrathecal dose for a man of 50 kilos (110 lbs.) to be about 3 grams
(46 grs.), i.e. about 20 c.c. of a 15 per cent solution of magnesium
sulphate. Meltzer, injecting the drug subcutaneously, produced
anaesthesia culminating in narcosis, reaching its climaLx in about three
to four hours and permitting of surgical operations by the end of the
second hour. Intravenous injections are more rapid in their effect,
and intrathecal injections still more so, but the risk of respirator}^
failure is greater. On the completion of the operation, after magnesium

NEW TREATMENT

6oi

TETANUS

sulphate anaesthesia, Meltzer and Auer recommend the withdrawal
of a small amount of cerebrospinal fluid, followed by irrigation of the
subarachnoid space with sterilized normal saline solution. If this be
done, they find that the paralytic phenomena clear up more quickly ;
also there is less risk of retention of urine or of root-pains in the legs.

Meltzer and Joseph, in discussing the relative toxicity of magnesium,
calcium, potassium, and sodium salts (all of which are normal consti-
tuents of the tissues) , maintain that their toxicity is in inverse propor-
tion to their amount in the blood serum. This explains why normal
saline solution is relatively innocuous, whereas magnesium salts, being
normally scanty, are specially toxic when introduced intra\^enously or
intrathecally,

Mathews and Clyde consider that the action of rnagnesium salts, in
producing paralysis of respiratory muscles, closely resembles that of
curare. Muscular tremors produced by physostigmine are removed by
magnesium salts. Now Pal showed that physostigmine is antagonistic
to curare. We are therefore not surprised to learn that, as Joseph
and Meltzer have shown, physostigmine arrests the paralytic eft'ect of
magnesium sulphate upon the respiratory muscles and promptly
improves respiration, notwithstanding that the general muscular
fiaccidity and anaesthesia persist unchanged for hours.

With regard to the Treatment of Tetanus by Magnesium Sulphate,
Henderson originally introduced the solution through a small trephine
opening direct on to the cerebral cortex by means of a special needle.
Kocher, however, introduces the drug through a lumbar-puncture
needle. Discarding the stronger solutions used by him in his earlier
cases, he administers 5 c.c. of a 15 per cent solution. A sleep
similar to that following a narcotic is usually produced within an hour,
and lasts two hours or so. If stronger solutions, e.g. 25 per cent, be
introduced, the effects are too intense, the unconsciousness may last
twenty-four hours, and oxygen inhalation may be necessary ; the
w’eaker solution is safer, and produces all the desired effects, especially
if the lower part of the trunk be raised so as to favour diffusion of the
drug towards higher levels of the body.

In view of the possible effects on the respiratory centre, other observers
confirm the view as to the desirability of a suitably diluted solution.
Thus Blake, who at first gave four daily injections, each of 4*5 c.c. of a
25 per cent solution, later gave 8 c.c. of a 12*5 per cent solution, and
obtained complete cure. Kocher emphasizes the helpfulness of oxygen
inhalations should respiratory failure threaten, and if the heart also
becomes suspiciously slow he recommends an intravenous injection
of atropine gr. Arndt, on the other hand, prefers to combat respira-
tory failure by washing out the lumbar cavity with normal saline solu-
tion after the method of Meltzer and Auer.

Tidy 2 records a case of tetanus in a boy of eight treated by intrathecal
injections of 3 c.c. of a sterilized 25 per cent solution of magnesium
sulphate at intervals of three and four days. The spasms subsided,
and the patient was discharged cured. Three days after the last injec-

TETANUS

602

MEDICAL ANNUAL

tion of magnesium sulphate, when the patient was already convalescent,
a subcutaneous injection of antitetanus serum was also administered.

In an excellent review upon the subject, Ashurst and John,® of
Philadelphia, discuss the rationale of treatment, and report twenty-
three consecutive cases of tetanus treated in hospital during the last
eight years. The following are their more important conclusions :■ —

Tetanus is a pure toxaemia. The tetanus bacilli or their spores may
exist in the tissues indefinitely, but no symptoms are produced unless
toxins are formed. Moreover, if the toxin be introduced into the
system it produces all the symptoms of tetanus, even though no bacilli
are present. In the small animals used in laboratory experiments for
the injection of tetanus toxin, the symptoms usually begin in the
inoculated limb, developing first in the injured part and gradually
ascending — so-called ietamts ascendens. But in the larger animals,
and in man, in whom the disease is acquired, not by the injection of
toxin but by inoculation with tetanus bacilli, the symptoms begin in
the muscles of the neck and jaws, no matter where the point of inocula-
tion has been. The muscles of the back and limbs are affected later,
the lower extremities being attacked last of all. The disease is, there-
fore, distinguished as tetanus descendens. The probable explanation of
these differences was advanced in 1909 by Sawamura. In experimental
animals the toxin is injected into the muscles, usually of the lower limb,
and thus, coming into close relation with the adjacent motor nerves, it
is rapidly absorbed by them and conducted upwards to the correspond-
ing area of the spinal cord, producing tetanus of the infected limb. In
man, however, the usual point of inoculation is not intramuscular, but
ill the subcutaneous tissues of the hand or foot, and the toxin. produced
in the wound is absorbed into the lymphatics and general circulation.
It is thus carried to the end-plates of all motor nerves throughout the
body. The toxin then advances up the various nerves towards the
brain-stem. The shortest nerves being those of the facial, masticatory,
neck, and spinal muscles, tetanic toxins reach the brain-stem, and
produce tetanic spasms in the muscles supplied by these ner\xs before
the toxin in the wounded extremity has had time to ascend the long
nerves of that limb to the corresponding part of the cord. Ascending
tetanus is uncommon in man, and when it does occur, it is usually
found that the point of inoculation was muscular (22 out of 23 cases
of ascending tetanus collected by Saw^amura). Cephalic tetanus
following wounds of the face and head is an ascending tetanus.

In experimental tetanus the tetanus toxin ascends the peripheral
nerves to the spinal cord, not only along the peri- and endo-neurium,
but also, as Meyer and Ransom have shown, by way of the axis-cylin-
ders. Only when it reaches the brain-stem does it begin to produce
symptoms, corresponding to the area of spinal cord or brain which is
attacked. The nearer the toxin gets to the spinal cord, the more
intimately does it become combined wdth the nervous tissue.

The mciihation period depends on the distance from the cord of the
site of injection of the toxin. Having reached the cord, the toxin

NEW TREATMENT

603

TETANUS

diffuses up and down it. Some of the toxin enters the general circula-
tion and can be detected in the blood. This toxin, being carried to the
motor end-plates throughout the body, eventually reaches the cord as
above described, and produces descending tetanus. The toxin stimu-
lates the motor cells of the cord, producing tonic spasm of the corres-
ponding muscles. It is unnecessary to recapitulate the classic sym-
ptoms of tetanus ; but it may be recalled that the slightest stimuli,
e.g. slamming a door, jarring the patient’s bed, a sudden draught of
air, etc., at once intensify the spasms.

Preventive Treatment. — It is well known that the tetanus bacillus
is anaerobic, and that, normally infesting the intestinal tract of horses
and cattle, it is deposited with their dung, and is found in farmyards,
stables, gardens, and streets. According to Fox, tetanus bacilli are
found in the faeces of 5 per cent of mankind, and in the faeces of 20 per
cent of men who work amongst horses. On these accounts, therefore,
wounds sustained by farmers, gardeners, stablemen, etc., and wounds
contaminated by dust or mud, are specially likely to be infected with
tetanus bacilli. Infection is favoured by an anaerobic condition of the
wound. Sloughing tissues are particularly good culture-media. A
mixed infection, especially with saproph3rtic bacteria, is favourable for
development of the disease, because these organisms, being aerobic,
absorb all the available oxygen, and provide anaerobic conditions for
the tetanus bacilli. Careful attention to the original wound is therefore
the first and most important step in the prevention of tetanus. Ashurst
and John treat a suspected wound as follows : The surrounding skin is
painted with a 3 per cent alcoholic solution of iodine. Ail parts of the
wound are then made freely accessible, by wide incision if necessary.
The wound is carefully cleaned up with scissors and forceps, and is
then thoroughly swabbed out with the iodine solution. Finally, it is
lightly packed with gauze soaked in iodine solution. All caustics are
avoided, since the presence of sloughs, however minute, favours the
growth of tetanus bacilli. At subsequent daily dressings of the w^ound
it is irrigated -with peroxide of hydrogen until active effervescence
ceases, and is again packed with gauze soaked in iodine. Prophylactic
injections of Tetanus Antitoxin are given, one at the very start, prefer-
ably intramuscularly rather than subcutaneousl}", and in the vicinity
of the ■wound. If any nerves are exposed in the -wound, the antitoxin
should be injected into them. The antitoxin is completely eliminated
in about eight to ten days; hence a second injection should be given at
the end of seven or eight days, and a third injection during the third
w^eek. In fifty-five cases collected by Ramertz w^here tetanus developed
in spite of the prophylactic use of antitoxin, nearly all were cases in
which only one injection w^as given. It is doubtful w^hether this is the
main reason for the relative failure of antitoxin alone to prevent tetanus
in man, as compared with its most successful action in horses. Possibly
the fact that horses are treated by antitoxin derived from their own
serum, while human patients are treated by an alien (horse) serum,
makes a difference.

TETANUS 604 MEDICAL ANNUAL

If symptoms of tetanus have already appeared by the time the
patient comes under treatment, then, in addition to cleansing of the
Avoimd as above described, Ashurst and John proceed to give intra-
spinal and intraneural injections of antitoxin, for reasons to be presently
referred to. In wounds of the sole of the foot, the sciatic nerve should
be selected for intraneural injection ; for the upper extremity, the
brachial plexus should be exposed above the clavicle, and an injection
made into each of its cords.

Ashurst and John discuss the therapeutic use of tetanus antitoxin.
The following sites of injection have been advised : subcutaneous,
intravenous, intraspinal, intraneural, intracerebral, and intramuscular.
Subcutaneous injection, although it is the method most usually em-
ployed, is the least efficacious, since only a fraction of the antitoxin
ultimately reaches the motor nerves and spinal cord, while the main
mass of the injection is distributed to the viscera, where it can be of no
possible use. Administered in this way, overwhelming amounts,
100,000 units at least in twenty-four hours, are required to produce
any effect. Intravenous injection is rather better than subcutaneous,
and is easier than intraspinal or intraneural injection. Intraspinal
(subdural) injections are better still, and from 3,000 to 10,000 units
should be given, according to the severity of the case. This may be
repeated in eighteen to twenty-four hours if necessary. Intraneural
injection into the nerve-trunk of the affected limb may be used as an
important accessory to intraspinal injection. As much antitoxin as
the nerves will absorb should be given. One thousand five hundred
units have been injected into the sciatic nerve, and 750 units into the
anterior crural and obturator nerves. Intracerebral injections present
no advantages over intraspinal, and have the drawback of occasionally
causing lasting damage to the brain. Intramuscular injections are
better than subcutaneous, but inferior to intravenous, and cei'tainly
much inferior to intraspinal and intraneural.

As to the frequency of injections of antitoxin, the usual fault is that
it is only given once. When given intravenously, it should be repeated
in twelve to twenty-four hours. Intraspinal injections should be given
at longer intervals, say one to three days. Intraneural injections can
be repeated daily if required. No matter what the channel of adminis-
tration be, the important thing is to get the maximum amount of anti-
toxin in contact with the spinal cord and nerves, as soon as possible.

Ashurst and John refer to Baccelli*s treatment by the injection of
I c.c. of a 4 to 5 per cent solution of Phenol into the muscles until So or
100 egrams are given in twenty-four hours. They admit the excellent
results obtained by the Italian school by this method, and refer to the
tolerance of tetanic patients for carbolic acid ; hut they themselves only
employed it once in a series of tw^^enty-three cases. They also refer to
the relief afforded by intraspinal injections of Magnesium Sulphate, its
action being mainly that of a spinal depressant. To depress the func-
tions of the spinal cord is undoubtedly an important indication, but
care must be taken not to produce respiratory failure by an over-dose.

NEW TREATMENT ( 3 o 5 THYROID GLAND SURGERY

Other points of importance as regards the management of the patient
are to attend carefully to the feeding and to the bowels. Nasal feeding
may be necessary. Retention of urine must be watched for, and
relieved by catheter. Isolation is desirable in order to protect the
patient from noise. Slamming of doors, loud talking, rattling windows,
etc., should be jprevented. The patient’s ears may be stopped with
cotton-wool and the floor heavily carpeted.

Ashurst and John record 23 cases of tetanus observed by them-
selves. Of these, 10 recovered and 13 died, making a total mortality
of 56-5 per cent. In 5 of these cases, where efficient treatment was
begun within twelve hours of symptoms, only i died, making a
mortality of 20 per cent under these conditions. In 18 cases where
efficient treatment was delayed beyond twelve hours of symptoms,
12 died, i.e., a mortality of 66-6 per cent. Antitoxin was used in all
23 cases ; efficiently as to method and quantity in 12 cases, with a
mortality of 46’ i per cent; and inefficiently in ii cases, with a mor-
tality of 72*7 per cent. .

References. — med. Woch. 1913, Mar. 20; Kimer. Jour. Med. Sci.
1913, i, 86c, and ii, 77.

THREAD-WORMS. Roheri Huichison,' F.R.C.P.

Hildebrand^ believes that the persistencj^ of the presence of tliread-
worms in some cases in spite of treatment is due to constant re-infection
of the patient by the conveyance of the ova from the neighbourhood
of the anus to the mouth. In order to prevent this it is necessary to
use some agent which will destroy the ova as soon as they pass the anus.
For this purpose he uses an ointment composed of Camphor, Quinine,
and Thymol,* which is applied thus : Morning and evening the peri-
anal region is thoroughly washed with soap and water; thereafter a
piece of the ointment var^dng in size from a pea to a cherry is smeared
over and around the anus. The procedure is repeated after each
action of the bowels, and before each meal the hands and nails are
thoroughly cleaned. The treatment must be continued for two or
three weeks. He has employed this plan in several very obstinate
cases, and has always found it prove successful.

Reference, — ’^ Munch . med . WocJt . 1913, 131.

THROMBOSIS. (See Operations, Complications Following ; Otitis
Media ; Vena Cava.)

THYROID GLAND, SURGERY OF. (See also Goitre, Exophthalmic.)

Priestley Leech, F.R.C.S.

Charles hla^-o^ gives the results of five thousand operations per-
formed in the St. Mary’s Hospital clinic, in Rochester, for the following
diseases of the thyroid gland : —

* Ung. Chinin. Camphorat Co. Supplied in collapsible tubes by Houten,
pharmacist, Emniendingen.

THYROID GLAND SURGERY

606

MEDICAL ANNUAL

Simple goitre, including ir transplantations in cretins . . 2396

Malignant disease (carcinoma 52, sarcoma 7 ) • • • • 59

Exophthalmic goitre, including double and single ligation,

total and partial thyroidectomy . . . . . . 2295

Syphilitic disease . . . . . . . • • . i

Early operations, not classified, the majority being simple

goitres , . • • • ♦ • • • • 309

Total , . 5000

The occasional large goitre in the cretin has but little active paren-
chyma, and if it causes distress should be removed. Mayo has repeat-
edly transplanted fresh gland from the mother, and also from fresh
simple and exophthalmic goitres, but in no case did the transplanted
gland functionate, though for a short time it furnished secretion by
absorption. Paresis of the fecurrent laryngeal nerve is fairly frequent
from pressure of a goitre, and if the cords are not examined before
operation, this latter may be blamed for the change in the voice. Second-
ary paresis may occur from scar tissue resulting from traumatism due
to a too large exposure of the nerve. Intrathoracic and deep subsiernal
goitres are of serious import, and are found about once in fifty opera-
tions for simple goitre. The diagnosis rests in a dull area on percussion,
skiagraphy, evidences of substernal pressure (dilated veins, obstructive
dyspnoea), and palpation of the upper pole of the gland just above the
clavicle. Injury to the parathyroids is best avoided by preserving
the posterior capsule, especially when both sides are operated on ; and
as they are difficult to, identify, it is best to leave all small glandlike
bodies beneath or connected with the posterior capsule. Treatment
of post-operative tetany with Calcium Lactate, and also Beeves' Para-
thyroid with Thyroid Extract, has been very effectual.

Many forms of simple goitre, especially of the adolescent type,
undergo a natural resolution. Iodine is sometimes useful. More
recent experience seems to indicate the use of Thymol and Salol as
intestinal antiseptics. In exophthalmic goitres, temporary improve-
ment has been obtained by the use of X-rays, which also seem to be
of use in carrying serious cases through exacerbations. The cytolytic
sera have not given the results expected.

The best incision is the low transverse one. In simple goitres, a
greatly enlarged lobe should be extirpated. If both lobes are sym-
metrically enlarged, division of the isthmus with double resection of the
gland is indicated as giving the best cosmetic results. Mid-line encap-
sulated adenomata should be enucleated, with division of the isthmus.
Lateral encapsulated adenomata may be enucleated or the whole lobe
extirpated. If symptoms of hyperthyroidism are present, extirpation
is indicated. In severe cases of hyperthyroidism, in acute attacks and
relapses or exacerbations, the condition should be considered medical
until improvement takes place. If no improvement occurs. Injections
of Boiling Water into the lobes (Porter) may give relief. During the
first three or four months of the symptoms, extirpation can safely be
made, since the heart then is not dilated. If it is dilated to exceed one

XEW TREATMENT

607 THYROID GLAND SURGERY

inch, primary ligation of the superior thyroid vessels is indicated,
followed in four months by extirpation. After the first year of symp-
toms a much smaller percentage of cases requires primary ligation. A
single test ligation ma^’ be made in doubtful cases, to be followed in a
week by a second ligation or partial extirpation according to the degree
of reaction. The records of a large number of patients show an average
gain of 2 2 lb. within four months after ligation. These patients were
then operated on, a partial th\T:oidectomy being done with safety.
Following these methods the Mayos have performed 278 operations
on cases of hyperth37roidism between deaths.

Long-standing cases of simple goitre and adenoma may, by degenera-
tion or chronic slow thyrotoxicosis, cause serious disturbances in the
heart, kidneys, and blood-vessels ; this is especially true of patients in
middle and advanced life. When such complications are present,
operations are attended by considerable risk.

Excluding malignancy, the death-rate is low, and varies little in cases
of so-called simple goitre and so-called exophthalmic goitre. The
greater the delay the greater the mortality in exophthalmic cases ; in
Mayo’s first sixteen cases the mortality was 25 per cent, whereas it is
now I to 3 per cent. In cases of hyperthyroidism, operation appears
to give about 75 per cent of cures, while the remaining 25 per cent are
more or less benefited. Probably 10 per cent have some degree of
relapse in from one to three years after operation, usually manifested
by return of symptoms. In these rare cases, ligation of the vessels,
with removal of a portion of the remaining lobe, in most instances
improves the condition of the patient. Exophthalmos of marked
degree and long standing may still be present when other symptoms
are cured.

In patients in good general condition a general anaesthetic, ether b}’-
the drop method, is preferred, with ^ gr. of morphine and -j-ly gr, of
atropine half an hour before the operation. If general anaesthesia be
inad^dsable. free local injections of 0*5 per cent solution of novocain
are given. A combined local and general anaesthesia, as advocated by
Crile, may be of advantage in certain cases. Intratracheal anaesthesia
is indicated in those cases of “ scabbard ” or distorted trachea, in which
the patient is already suffering from d^’Spnoea, especially in the presence
of malignant disease of the thyroid, and complications due to enlarged
th^mius.

Crile, in course of a discussion, said he had no more doubt as
to the benefits of operation in exophthalmic goitre than of that of
opening an abscess. He had never seen recovery in a single case of
cancer of the thyroid diagnosed as such before operation ; he had seen
a few cases cured in which cancer, previously unsusjDected, was found
by the operator.

Porter^ has tried the Injection of Boiling Water in exophthalmic
goitre. He has treated over twenty patients with one hundred injec-
tions ; the quantity injected at each point varied from 40 to 230 min.
The largest quantity injected at one treatment was 660 min., equally

THYROID GLAND SURGERY 60S MEDICAL ANNUAL

divided between the isthmus and the right and left lobes. The
immediate effect is destruction of th3TOid tissue and colloid. A
further destruction of thyroid cells occurs as a result of the consequent
formation of fibrous tissue. Local anfesthesia at the point of puncture
abolishes pain. Four patients were cured. He uses an all-glass
graduated syringe, and injects inside the capsule. He thinks it will
prove of value in cases Avhich are not good surgical risks. Reports of
cases are given, and also the histological results of injection into the
th3n*oid of dogs.

Berry, ^ in the Lettsomian Lectures, considered the surgery of the
thyroid gland with special reference to exophthalmic goitre. He pro-
fesses a profound scepticism as to the present teaching, especially
that of America, as to the functions of the parathyroids. In all cases
of Graves’ disease there is a persistent th^mius, and Beny sa^^s he
has never failed to find the condition in of the autopsies in cases
which he has seen. The th^u'oid always shows the same structure,
and may easily be recognized by the naked e\'e ; the gland, instead of
presenting the vesicular appearance characteristic of the normal tissue,
or of the ordinary parenchymatous goitre, looks solid and almost homo-
geneous, like a salivary gland or the pancreas. In cases to which he
gives the name of secondar}’ Graves’ disease, there is evidence of
previous goitre, as shown by fibrosis, calcification, adenomatous or
c^’stic degeneration, etc. ; but in these cases the Graves’ disease is not
caused by the previous goitre, and is a separate occurrence. This view
is strengthened by the fact that exophthalmic goitre is no more common
in regions of endemic goitre than it is elsewhere, as would be the case were
this latter a predisposing factor. There is no evidence that Graves’
disease can occur without thyroid hyperplasia, and there is a definite
relation between the sjmiptoms of the disease and the condition of the
gland.

Medical treatment does nothing to cure the disease. Many cases
abort at an early stage, and come to an end spontaneously ; in many
instances, where the patient can take abundant rest, the disease wears
itself out. He thinks rodagen and the milk of thyroidectoniized goats
of but little value. X-ray Treatment is of real use ; it is most suitable
for early cases, and also for acute ones, in which operation is dangerous.
He is doubtful as to the value of any serum.

As regards Operation in exophthalmic goitre, Berry has lately modi-
fied his opinion. Anything like indiscriminate operating for this
condition is to be strongly deprecated. Operations on the acute and
advanced cases are ver^^ dangerous and not to be lightly undertaken.

“ Advanced ” cases are not those of long duration, but rather those in
wliich the intoxication is acute, and secondary degenerations of viscera,
especialty of the heart, are present. The difficulty in considering the
question of operation is the question, What is exophthalmic goitre ?
If we only include the well-marked cases, we shall find the operative
mortality is very much higher than if w^e follow the tendency of the
present day and include many cases which have not well-defined

NEW TREATMENT

609

THYROID GLAND SURGERY

symptoms. A patient \^ith an ordinary parenchymatous goitre, or an
adenoma or cy’st of the thyroid, who has some tachycardia, and com-
plains of palpitation, is regarded by some observers as a mild case of
exophthalmic goitre, by^ others as a case of hy’perthyrroidism, and
therefore belonging to the same class, despite the fact that the majority
of such patients, if allowed to progress, never develop exophthalmos or
the more serious symptoms.

Two main facts stand out : (i) The danger of the operation as often
performed ; and (2) The undoubted benefits that results in a large
proportion of the cases. Care should be exercised in drawing conclu-
sions from mortality statistics of published records ; probably the
only safe test is the pathological one, and mortality statistics based on
pathological findings are rare. Another difficulty^ is that cases of
Graves', disease do not pursue a uniform and progressive course. One
may go from bad to worse, and another come to an end spontaneously.
If we knew that every case would go progressively down hill, the dangers
of operation would require less consideration.

In Berry’s opinion, operation should not be undertaken in acute cases
where there is much thyi’oid intoxication, as shown by great excitability,
mania, or muscular weakness ; or in those suffering from any acute
infiammatory afiection, such as acute bronchitis, or in those cases in
which marked degenerative changes have taken place in the viscera,
especially in the heart and kidneys. Albuminuria, gly’^cosuria, diarrhoea,
a constantly irregular pulse and low blood-pressure, are all conditions
which should lead the surgeon at least to postpone operation ; if these
conditions cannot be remedied by medical treatment, no operation
should be performed. Of all chronic complications, marked dilatation
of the heart is perhaps the most common and serious.

Of Berry’s own operation cases, with the exception of two that died,
all have benefited, although in one or t^vo the benefit has not been
great, and in one case at least there has been a slight relapse. Even
after a single ligation, patients nearly always say they feel better ;
the objective signs of the disease may remain, but still the patients
feel better, and can lead a more active life than formerly.

As regards the ancesthetic, chloroform is more dangerous than ether ;
ether by the closed method is more dangerous than open ether ; while
local analgesia is most suitable for the severe type of case if the patient
is willing to submit to operation under these conditions. Its main
advantage is that the patient can drink freely during and immediately
after operation ; the principal disadvantage is the psychic effect upon
a nervous patient. It is important not to operate upon any one who
is in a condition of great alarm.

The operation of choice in exophthalmic goitre is removal of part of
the gland ; next to asepsis, efficient haemostasis is the most important
point. The danger of bruising or crushing the gland is greatly over-
rated, and the so-called attacks of acute thyroidism are not to be
explained solely, if at all, by mere manipulation. The most important
point in after-treatment is the administration of large amounts of

THYROID OLAND SURGERY

6lo

MEDICAL ANNUAL

water immediately after operation, either by the mouth or rectum, or
even subcutaneously in the form of saline solution. Ligation of
arteries has a well-established position ; ligation of the superior thyroid
can often be performed with more safety than a hemithyroidectomy ;
ligation of the inferior th3a'oid is a difficult and somewhat severe pro-
cedure, and should rarely be adopted. ligation of both superior and
one inferior thyroid arteries may be quite as severe as removal of half
the gland.

It is best to tie the arter^r close to the gland, and even to include in
the ligature the upper pole of the gland itself, ahd to tie vein and artery
together. Berry does not think that if removal of one lobe does not
cure the disease, the other half should be removed, but only a portion
of it, as the risk of m\^xoedema is too great. There are persons who
cannot take th^noid extract. He, like Mayo, has seen no proof that
thyroid grafting can be relied on to take the place of normal gland.
From these extracts it will be seen that Berr^/’s attitude towards opera-
tion in Graves’ disease has changed, and he is now more in favour of
operating than formerly.

Halsted,-^ of Baltimore, in 39 cases of Gra^'es’ disease has excised
the greater portion of both lobes of the thyj'oid gland at two or more
operations. Several of these patients, operated upon as long ago as
1902 and 1903, are still under observation and in perfect health.
In all cases the second lobe was removed because excision of the first
had been followed b^’' insufficient improvement. In several instances
ligation of three arteries with excision of one lobe had been attended
with almost negative results, and relief from all symptoms followed
immediately upon removal of the remaining lobe ; hence the advisa-
bilit}" of removing the first lobe in such a manner that the second may
be excised without danger of tetaii}?-. A small slice of each thyroid
lobe is left, in order to protect the circulation of the parath^^roid
glandules. The vessels are clamped at a safe distance from the para-
thyroids, and ligated after the lobe has been cut awa^^ No muscles
are divided. Haemostasis is attended to with scrupulous care, and the
wounds are closed without drainage. No deaths occurred.

He thinks the thymus plays an important role in cases of Graves’
disease. With advances in skiagraphy it has become possible to detect
enlargements of the thy^mus too slight to be determined by percussion ;
it seems probable that in 75 per cent or more of the pronounced cases
the thymus is enlarged. Kocher has drawn attention to the importance
of l^^mphoc^dosis in Graves’ disease ; and Halsted has found that
almost invariably the proportion of lymphocytes was increased, being
as high as 65 per cent in one case. In the most serious of all,
how^ever, the percentage of lymphocytes w'-as only 9, After operation
there has been a gradual reduction in the number of lymphocytes, and
apparently also in the size of the thymus.

In no single instance has tying of two, three, or even four arteries
sufficed to cure the patient seriously ill with Graves’ disease, though
considerable improvement may follow the ligation of even a single

NEW TREATMENT

6ii

THYROIDITIS

artery. .For the last two years he has tied the inferior thyroid in
preference to the superior, for the following reasons. The cosmetic effect
is better ; if a lobe is excised later the incision is through fresh and not
scar tissue ; the inferior artery is larger, and the effect of ligation may
be greater ; if a lobe is removed later, when the superior artery is tied,
all four arteries will have been occluded ; the position of the inferior
artery is less variable than that of the superior. The inferior thyroid
is ligated as follows : A transverse cut from 4 to 4*5 cm. in length is
made over the tendon of the omoh5^oid muscle precisel}^ in the line
of the Kocher collar incision ; the fibres of the sternomastoid muscle
are separated in the line of the common carotid artery at the level
of the omohyoid tendon. The thyroid lobe is exposed behind the
posterior fibres of the sterno-thyroid muscle, and drawn inward by a
retractor designed for this purpose. The common carotid is retracted
outwards by a similar though somewhat shorter instrument, and the
layers of fascia covering the inferior thyroid artery are divided at the
level of the omohyoid tendon. The dissection is carried out by means
of two long delicate blunt dissectors. A special aneurysm needle is
used for carrying the fine silk ligatures around the artery, and the
wound is not drained.

References. — '^Jouv. Amer. Med. Assoc. 1913, ii, 10; 88 ; ^Lancet,

1913* i 583 ; ^Ann. Surg. 1913, ii, 178.

THYROIDITIS. Hevhert French, M.D., F.R.C.P,

Etiology. — Acute non-suppurative th3TOiditis is met with not only
in Brazil, as described by Chagas (see Goitre, Endemic), but also in
Europe ; and in support of the \dew that it owns a microbic cause
is the fact that whereas most cases subside spontaneously, a few go on
to abscess formation ; whilst in support of the further view that it
may have several different microbic causes, is the fact that it may
follow or be associated vdth, such various maladies as acute rheuma-
tism, diphtheria, erysipelas, parotitis, orchitis, erythema nodosum,
typhoid fever, malaria, syphilis, and tuberculosis. Robertson^
collected and analyzed g6 cases, and over a score of references to the
literature of the subject are given by Lublinski.^

Symptoms. — Clinically, the affection is generally recognizable without
much difficulty, though it may sometimes be simulated by acute diffuse
hyperplasia of the gland, inflammation of the lymphatic glands in the
immediate neighbourhood, haemorrhage in the thyroid, or a rapidly
growing malignant tumour of the organ. The onset is generally sudden,
with pyrexia and often a rigor ; there is a feeling of severe illness, with
vomiting, and aching of the head, especially behind the ears and in the
occipital region. The pulse is full and hard, between 100 and 120 ;
the temperature is remittent, and may rise as high as 104° F. Often
on the first day, but otherwise not later than the second or third day,
an uncomfortable feeling of tightness in the front of the throat develops,
with pain that is increased on movement of the neck ; and simul-
taneously the thyroid gland can be felt to have swelled, generally as

THYROIDITIS

612

MEDICAL ANNUAL

regards one lobe more than the other ; occasionally the isthmus alone
ma\r be involved. The swelling is acutely tender, firm rather than
elastic, and the skin over it feels hot though it is seldom reddened,
and always movable over the tumour, whilst the trachea and larynx
are sun'ounded by the latter and united firmly to it. Subjectively,
besides the oppression and feeling of tightness, there are pains which
radiate wddely from the primary focus to the ear, the back of the
head, and the shoulders ; there is an extreme sense of suffocation,
with wheezy breathing and irritating cough, the sputum being
mucoid and often blood -tinged. Paralysis of a recurrent larjmgeal
nerve is not uncommon ; it occurred in four out of eleven of
Lublinski's cases ; the cervical sympathetic is also apt to be inter-
fered with, leading to ptosis and increased sweat secretion on the most
affected side.

These symptoms attain their maximum about the end of the first
week, and then they subside gradually ; the remittent fever ceases,
the tension decreases slowly ; but there is generally some sense of
abnormality hi the neck for several weeks after, in addition to which,
when the inflammation has subsided on one side it may repeat itself
upon the other. The prognosis is favourable.

Treatment. — No operative measures are required as a rule ; .
exceptionally. Tracheotomy, or division of the isthmus, may be needed.
As a rule it does not pass on into suppuration, though this is, of course,
a possibility.

References. — ^Lancet, igii, i. 930; '^BevL klin, Woch. 1913. 834,

TINNITUS (Noises in the Ear). Geo. L. Richards, M.D.

Wittmaack^ finds this one of the most troublesome of aural
symptoms. He advises that, before treatment is undertaken for
these noises, a careful search for the underlying cause be made. Some
are circulatory in chai*acter, and in many cases are directly transmitted,
as from aneurysm, increased blood -pressure, anaemia, and cardiac
diseases. The treatment should be directed to the cause only. In
another class the noises are of a nervous type, and the patienf is best
treated by having in his room some clock or watch which, by very loud
ticking, w'ill take away the annoyance of the tinnitus. The device
which produces a sound nearest to that of which the patient complains
is the best. The patient should sleep in the noisiest room in the house,
and after a time becomes impervious to the aural noises.

The group of cases in which the noises are dependent upon changes
in the sound apparatus itself are of two classes, those depending upon
pressure in the external canal (e.g., cerumen), and in the causation of
which all the acute and chronic afiections of the middle ear may be
concerned. Noises dependent upon morbid processes in the internal
ear may be caused by the degeneration of the sound-perceiving appar-
atus itself, and the nerves directly therein concerned. The noises vary
greatly in character. The treatnient of these two classes must have
for its basis the original cause, so far as can be determined. Various

NEW TREATMENT 613 TINNITUS

medicines, such as quinine and salicylic acid, may produce ear noises.
The prolonged use of alcohol and nicotine, organic ner\"e affections
such as tabes, and constitutional diseases such as nephritis, diabetes,
pernicious anaemia, leukaemia, and the like, may be the cause.

Remedies which lessen the sensitiveness of the nerve apparatus
are the Bromides and Valerian. \\Tien no specific cause can be deter-
mined, it may be of advantage to use Iodine, Pilocarpine, Arsenic, or
Thyroid preparations. The best Hydrotherapeutic methods are
bathing the feet in hot water and the Sitz Baths. Reactive hyperaemia
may be produced by Massage, Bougies, Electrolysis, Hot Air applica-
tions, the Electric Current, and the like. It is only after careful con-
sideration of all the factors in the case that the noises can be properly
treated ; even then in many instances the results are far from satisfac-
tory, and the question of complete destruction of the lab^Tinth may
have to be considered if the noises are sufficiently annoying to the
patient.

Powder^ has obtained some relief from cases of tinnitus hy the
application of a Tight-constricting Neckband; this gives relief by
increasing the labyrinthine pressure or by relieving the under- tension
in the middle ear, which is brought about by the congestion out-
balancing the weighing effects of this congestion on the middle -ear
mechanism. In neurasthenic patients, relief from the tinnitus comes
after wearing the neckband for long periods of time, whereas in non-
neurasthenics relief is afforded as long as the neckband and other
appropriate treatment is continued. Tinnitus in otosclerosis is
influenced sometimes by the increased labyrinthine pressure induced
by the neckband, but rarely by the increased pressure in the external
meatus. In nerve deafness, a neckband will diminish tinnitus unless
its determining factor is extralabyrinthine, in which case it will but
rarely lessen it. In chronic non-suppurating otitis, if a constricting
neckband increases the tinnitus, the determining factors are mainly
in the middle ear, and are more or less influenced by treatment, according
to the character of the lesions. If a constricting neckband diminishes
the tinnitus, the determining factors are either in the lab^Tinth or its
walls, and are due to reflex irritations or to general conditions, such
as anaemia or neurasthenia, with or wdthout accompanying middle-ear
lesions. Prognosis in these cases is better than might be expected.
If meatus closure and the constricting neckband have no effect on a
marked tinnitus, the results are negative, and sclerotic conditions
probably exist. If the neckband diminishes tinnitus, and increased
air-pressure in the external auditory canal has no effect, there is
probably extreme ankylosis or otosclerosis.

Frazier^ suggests the intracranial DiYision of the Auditory Nerve
for the relief of such cases of tinnitus aarium as are so severe as
to cause grave neurasthenia or serious mental disturbance. The
appropriate cases are of labyrinthine origin, and may originate in the
vestibular ganglion, the cochlear ganglion, or in both ; and as there is
no means of separating the vestibular from the cochlear division, the

TINWITUS 614 MEDICAL ANNUAL

entire auditory trunk must be sacrificed. Cases of central origin must
be excluded. The best cases are those in which there is loss of air-
conduction, with preservation of bone-conduction, and a low-pitched
tinnitus. Complete deafness is one of the obstacles to be considered,
and, as a rule, the patient is already deaf on the affected side. For
the detailed technique the reader is referred to the original article.
The operation should only be done by those who are familiar with the
problems of the surgery of the posterior fossa.

References. — '^Deui. med. Woch. 1912, Sept. ; ^Laryngoscope, 1913, Mar. ;
^Joiiv. Amer. Med. Assoc. 1913, Aug.

TONGUE, CANCER OF. Priestley Leech, M.D., F.R.C.S,

Gorse and Dupuich^ report the case of a patient with epithelioma of
the tongue at twenty-two. There was no history of syphilis, and the
Wassermann reaction was negative. The disease was removed, but
recurred some months later, Lorsin, out of 342 cases of cancer of the
tongue, found 9 between fifteen and thirty years of age. Histological
examination is the only means of making a certain diagnosis. They
give a resume of the literature of thirty cases in young subjects so far
reported.

Reference. — ^Rev. de Chir. 1913, 293.

TONGUE, MARGINAL RESECTION OF. Priestley Leech, M.D., F.R.C.S.

Sampson Handley^ has given this name to an operation designed
and practised for some years by the late Sir H. T. Butlin. It is very
useful in tv’o classes of cases : when the tongue is originally, or has
become, too large for the mouth, and when its lateral margin shows

dangerous or annoying irritability
in contact with the teeth. Its
advantages are that the tongue
becomes reduced in size without
altering its shape, impairing its mo-
bility, or interfering wdth speech ;
the teeth after the operation lie no
longer in contact with a papilla-
bearing surface, but with smooth
mucous membrane derived from
the inframarginal surface of the
tongue ; and owing to the reduced
size of the latter,, its contact with
the teeth is not so intimate.

The technique is as follows : The
tongue is transfixed far back by a
stout silk ligature which helps to
control it. The excision of the
wedge is commenced at the tip of the tongue, and at first involves
two converging incisions about an inch and a half in length ; sutures
are then introduced {Figs, 76-78). The bleeding is thus stopped, and
the tongue can be manipulated by a loop of tissue, shortly to be

NEW TREATMENT

615

TONGUE

removed, but still attached at both ends like the handle of a hand-
bag. Making traction on this handle, a further portion of the marginal

wedge, perhaps an inch
long, is now cut along
the margin of the tongxie,
and again stitches are in-
troduced : the same man-
oeuvre is repeated on the
opposite side, and again
repeated, until the sutures
have been placed right
back to the last molar
tooth, where the V-shaped
notch is made more and
more shallow until the
posterior end of the wedge
is entirely free on both
sides and comes away.
By this method haemor-
rhage is reduced to a
minimum and the per-
formance of a laryngo-
tomy is avoided. In

Fig. 80. — Marginal resection of the tongue :
The strip of tongue removed (natural size).

TONGUE

6l6

MEDICAL annual

excising the wedge, the lower of the two incisions accurately follows
the junction between the rough mucosa of the dorsum and the
smooth mucosa of the inframarginal portion of the tongue, so that
none of the latter is sacrificed. Notes of two cases are given in which
this operation was performed.

Reference. — Jottv. Suvg. I 9 i 3 > July, 42.

TONSILS. [See also Adenoits.) W, G. Porter, M,B,, F.R.C.S.

Hett,^ as a result of his studies in the anatomy and comparative
anatomy of the tonsils, finds that they normally atrophy before adult
life, and so cannot have a function in adults ; and that in the
throats of the healthiest children they have begun to atrophy at
or soon after five years, while if they remain they are either
functionless, owing to the preponderance of fibrous tissue, or so
grossly pathological as to be a source of danger rather than protection.
He concludes that where operation is necessary, enucleation is the
method of choice.

Albuminuria in Association with Diseased Tonsils, — Baines and
CampbelP have made an examination of the urine from 760 patients
•who were to be operated upon for diseased tonsils. Of these, 24, or
3*2 per cent, showed albuminuria ; in 19 this w^as associated with
casts ; in 22 it disappeared in from one to six weeks after the operation ,*
while in the remaining 2 it persisted after eight and tw^elve months
respectively.

The Relative Value of Tonsillotomy and Tonsillectomy, — This is a
subject w'hich still gives rise to much discussion, and its importance
was recognized at the recent International Medical Congress, where it
was chosen as a subject for debate. J. L. Goodale, in his report,
enumerates some of the reasons justifying the assumption that the
system may dispense wdth the tonsils without detriment. First, if
the tonsils furnish something of value to the body, the other aggrega-
tions of lymphoid tissue in Waldeyer’s ring must have a similar func-
tion ; furthermore, in the last few years tonsils have been excised
without ill-effect on the system. If we admit that tonsillotomy often
fails to accomplish the result desired, why is not tonsillectomy always
the operation of choice ? Here the question of technique is of the
greatest importance. Goodale, after a preliminary injection of mor-
phine and atrophine, operates on the patient in a sitting position under
ether, and uses a head light ; a small sharp tenotomy knife is used to
dissect out the tonsil down to the tonsillar artery, and the snare is
employed to perform the final separation. Haemorrhage, in his experi-
ence, is slightly more frequent than after tonsillotomy, -but is readily
checked. Of the two operations, tonsillectomy shows a larger per-
centage of septic complications. As regards subsequent deformity,
if the tonsillectomy be skilfully performed it should not occur ; and
while gross deformities are unlikely to occur after tonsillotomy, yet
cicatricial occlusion of the lacunar orifices is frequent, and may lead to
an intensification of the original chronic inflammation.

NEW TREATMENT

TONSILS

617

The indications for operation should be determined by the -patho-
logical changes of the tonsils which are actually injurious to the indi-
vidual. Simple hyperplasia, if obstructive or favouring catarrhal
conditions, and if persistent, maj* be sufficiently treated by a tonsil-
lotomy, especially in children. Recurrent infections and local tuber-
culosis of the tonsils require complete tonsillectomy. In the case of
singers, if beginners, a partial or complete removal of the tonsils may
usually be done if the local condition demands it, but with increasing
length of singing experience a conservative attitude should be main-
tained.

Whale^ has compared the remote results of no tonsillotomies, and a
similar number of tonsillectomies. In cases where there had been
voice troubles, the best results were obtained after tonsillotomy, 15
being cured out of 26 ; while in 29 cases subjected to tonsillectomy,
14 were cured. Where lymphadenitis w^as present before operation,
43 per cent of cases were uncured by tonsillotomy, 33 per cent by
tonsillectomy. As regards haemorrhage after operation, only i case
occurred after tonsillotomy and 8 after tonsillectomy. Deformity
\vas found to occur in 21 per cent of cases after tonsillotomy, and in
23 per cent after tonsillectomy ; but harmful deformity was commoner
after the latter. The author concludes that the disadvantages of
tonsillotomy are : (i) Initiation of either tonsillitis, or lymphadenitis,
or both ; (2) Recurrence of the trouble for which the operation was
performed. The disadvantages of tonsillectomy are the risk of :
(i) Serious haemorrhage at operation ; {2) Harmful deformity ; (3)
Voice trouble. Thus tonsillectomy is the more dangex-ous operation,
but more likely to cure the disease.

Sheedy^ examined 50 patients, operated upon elsewhere, two or
three months after enucleation of the tonsils by various methods. He
found deformed throats in 40 ; of these about 5 per cent complained
of difficulty in using certain words, and had nasal intonation, and 2
had practicallj^ lost the singing voice. The deformities were of three
varieties. In the first, the pillars of both sides seemed to have disap-
peared, leaving a flattened surface and a narrowed opening into the
nasopharynx. In the second, the two pillars had joined, and the uvula
was pulled to one side or the other. In the third variety, the anterior
pillar had totally disappeared, and a large amount of cicatricial tissue
was deposited on the surface of the posterior pillar, which had altered
its shape and function. To avoid deformity, the author inserts a tonsil
tenaculum as far as possible into the centre of the gland, which he
endeavours to invert ; when this is achieved, a snare is passed over the
tonsil, which is then removed by slowdy tightening the snare, taking
from two to three minutes. He has never se^n deformity follow this
method of operation.

Techmque oj Tonsillectomy, — Sluder,® as a result of more extended
experience, believes he can remove 99*5 per cent of tonsils by his
guillotine, making use of the alveolar eminence of the lower jaw. His
instrumentarium has been modified owing to the difficulty some

TONSILS

6i8

MEDICAL ANNUAL

operators found in making the dull blade cut through the tissues. He
has added to the power of his original pattern by means of what is
described as a mechanic’s “ dog ” {Pig- 8i). It consists of a lever
with a hook on the distal end, which is engaged in a hole made in that
part of the shaft which becomes exposed after the blade has been
pushed across the aperture. At the point of the thumb-piece an arm

Si.— Mechanic’s “dog.” A, the hook for engaging in the shaft of the guillotine ;

B, “prong” for pressure on the thumb-piece of the guillotine. The “pitch” or biting
distance of the “ dog " is the difference between the distance from i to 3 and from i to 2,
or about I2 cn^i. C is a flange arising from the shaft, which fits into the crotch between
the thumb'and forefinger to "prevent slipiping of the hand when a single hand is used to do
the compression of the “dog” to the guillotine. D is the handle of the “dog,” made in
such form that it serves as a tongue-depressor.

2 1 in. long is given off at a right angle. As the dog ” is applied,
the thumb-piece is engaged just under the tip of the arm. The shaft
of the lever is then pushed down to make it lie parallel to the shaft of
the instrument. This may be done with one hand, as shown in Fig, 82.
The squeezing power of this leverage will be found to be very great.

George L. Richards® operates with the patient in the upright posi-
tion, and prefers finger dissection. The tip of the finger is inserted

between the anterior
pillar and the tonsil cap-
sule, detaching the upper
third of the latter, the
finger being then in-
serted betv^een it and
its attachments to the
superior constrictor
muscle and the adjacent
fascia. It is then grasped
with forceps and re-
moved with a snare.
General anaesthesia
should be employed.
Corwin 7 is a warm
supporter of Sluder’s
method. As an adjunct he uses a pair of tonsil haemostats ; one is
applied immediately the first tonsil is removed. He prefers general
anaesthesia with gas and oxygen. Carter® uses a tenaculum consisting
of two spiral prongs attached to a slender shaft, which is engaged in
the tonsil, and is then pulled towards the median line ; a sharp tonsil
separator is used to free the anterior and posterior pillars. The final
separation is carried out by Eve’s snare.

Fig, 82. — Setting of the |‘clog’’ to the guillotine and com-
pression by one hand. In this position the cutting may be done
as slowly or as rapidly as the surgeon may elect. The power of
the “ dog” thus applied is very great.

NEW TREATMENT 619 TRYPANOSOMIASIS

Halle,® to avoid reactionary hcBniorrhage, searches for the bleeding
points immediately after enucleating the tonsils, seizes them with
artery forceps, and t^vists them, ligature being unnecessary. For
veiy^ severe haemorrhage, he stitches the faucial pillars together or uses
clips. Skillem,^® in view of the increasing number of tonsil operations,
advises that a careful examination should be made in each case before
operating, to see that the internal carotid artery has not an anomalous
course. If it has, it may be seen pulsating in the pharynx in close
relation to the tonsil. If operation be essential in such a case, a
preliminary ligature of the internal carotid should first be carried out.

Complications after Tonsillar Operations, — Koplik^^has observed that
after operations on the tonsils (tonsillotomy or enucleation) certain
forms of infection are apt to arise. He distinguishes three types :
(i) A form which runs an obscure fever for a week or more without
causing endocarditic or other lesions ; (2) Those cases which show
pyrexia, and combine with it endocarditis, which may have a fatal
issue ; (3) A form of sepsis in which the infection is severely haemo-
lytic, and causes destructive blood changes with signs of sepsis, such
as profuse haemorrhagic ecchymotic areas on the skin, severe haemor-
rhages from the bowel, and areas of bronchopneumonia.

References. — '^Brit. Med, Jour. 1913, i, 743; '^Amer. Med, 1913, 410;
^Lancet, 1913, i, 444 ; ^Med. Rec. 1913, i, 654 ; ^Jour. Amer. Med. Assoc. 1913,
i. 650; Mbid, ii, 1231; ^Ibid, 1243; ^Med. Rec. 1913, i, 986; ^Beut. med.
Woch. 1913, 368; ^^Jour. Amer. Med. Assoc. 1913, i, 172; ^^Amer. Jour.
Med, Sci. 1912, ii. 30.

TORTICOLLIS, CONGENITAL. Frederick Langmead, M.D., F.R.C.P.

D. M. Greig^ records the case of a family in which congenital wry-
neck occurred in three generations. The family consists of father,
mother, and four children, two of each sex. Congenital wry-neck
occurred in the children’s maternal grandmother, the mother (an
only child), the second child (a girl), and the youngest (a boy). In
each of the four cases the torticollis is left-sided. No abnormality
of the bones was seen by x-idcy examination. Greig suggests that
the condition may be due to hereditary transmission of some
slight pelvic defect in the mothers, with a consequent tendency to
malposition of the foetus in utero.

Reference. — ^Brit. Jour. Child. Dis, 1913, 337.

TRIGEMINAL NEURALGIA. {See Neuralgia.)

TRYPANOSOMIASIS. Leonard Rogers, M.D., F.R.CP.

In a discussion on this subject at the British Medical Association,^
J. W. W. Stephens and H. B. Fantham described a new form of trypano-
some from a case of sleeping-sickness from Rhodesia, which is charac-
terized by the nucleus being situated at the posterior end of the organism
near the blepharoblast in some of the stumpy forms. They have
named it Trypanosoma rhodesiense. In two further papers, the same
authors ® record the results of a large number of measurements of

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their new trypanosome compared with those of T. gambiense and 2\
bfucei. They found that T. rhodesiensa more closely resembles the
latter than the former, although it can only be clearly distinguished
from that of the original form of sleeping-sickness by the posterior
situation of the nucleus. C. M. Wenyon,*^ however, has found a posterior
nucleus in T. pecmtdi, originally obtained from a donkey in the Sudan,
and thinks this character insufficient for distinguishing species. He
remarks that some authorities regard T. pecaiidi and hrucei as identical.
iMesnil^ confirms the results of Stephens and Fantham in differentiating
the Rhodesian form of human trypanosome, although he finds it to be
more closely allied to T. gamhieme than any other variety. A. King-
horn and W. Yorke^j ® describe a number of trypanosomes found by
them in wild game, or obtained by feeding wild tsetse flies on monkeys
in north-eastern Rhodesia. At least 37*5 per cent of wild buck harbour
parasites. They describe still another new trypanosome of game,
which they call T. ignoiitm, T\vo further reports have appeared by the
same workers ® including their final report from Rhodesia. They
show that the development of T. rhodesiense in Glossina morsiians is
greatly influenced by temperature, high degrees (75° to 85° F.) being
favourable, while lower ones (60° to 70° F.) are unfavourable. At such
low temperatures, however, the parasite may survive in an incom-
pletely developed stage for at least sixty days, and subsequently
complete its development to an infective stage if placed in a favourable
temperature, thus explaining some recorded Jong-latent periods of
infectivity of the flies. The relative humidity of the atmosphere did
not appear to influence the development. They proved that Glossina
morsiians transmits 2\ rhodesiense in nature, and that a considerable
proportion of local game W'as infected by it. The organism first
develops in the gut, but it is not until the salivary glands are invaded
that the flies become infective, the latter form being smaller and
shorter than the intestinal stage, but both are infective when inoculated
into healthy animals. Coloured plates illustrate the final report.

David Bruce, D. Harvey, A. E. Hamerton, and Lady Bruce- publish
two further reports on their investigations in Nyasaland.^®^ They
made a large number of measurements of the lengths of five strains of
human trypanosomes. Two of the curves so obtained corresponded
with those of Stephens and Fantham, while three approached more
nearly the type described b}^ Kinghorn and Yorke. The percentage
of postei’ior-nuclear forms differed widely in various strains of T.
rhodesiense, The)r conclude in the first paper that evidence is accumu-
lating to show that T. rhodesiense is identical with T, brucei. In the
second report they test this important supposition further, and for
that purpose obtained a strain of nagana from the same spot in Zulu-
land where David Bruce first discovered it, and were surprised to find
quite as large a proportion of posterior-nuclear forms as in T. rhode-
siense ; so they conclude that the two are identical, and that the new
human trypanosomiasis of Nyasaland is nagana. They also record
further examinations of game for infection, which showed that the

NEW TREATMENT

621

TRYPANOSOMIASIS

waterbuck, liartebeest, reedbuck, and duiker are dangerous enemies
to man, and the eland, kudu, bushbuck, and buffalo to cattle, goats,
and sheep. Their results in udld animals closely correspond to those
of Kingliorn and Yorke. They thus reach the very important con-
clusion that in areas in which tsetse fly abound, these wild animals
should no more be protected by game laws than mad dogs should
be in England, but on the contrary, active measures should be taken
to rid the hy-infested areas of them, although this is unnecessary
where the disease-carrying flies do not exist. W. Yorke^^ advo-
cates the destruction of big game as a preventive measure against
sleeping sickness.

G. H. F. NuttalF^ has published an instructive review of trypanoso-
miasis, dealing both with human and animal diseases, and with the
work of ]Minchin and Thompson on the transmission of T. lewisi of
rats through the rat flea. He points out that our present methods of
diflerentiating species are lacking in precision, tiy^panosomes varying
greatly on passage through different animals, while immunity reactions
are not a safe basis of classification.

L. E. \V. Biyan^^ has described a trypanosome-producing disease in
man and in dogs and goats, all of -which gave very similar measure-
ments. (It appears probable that this is 2'. rhodesiense,)

Treatment. — 'M. Gamble^* reports several cases of sleeping sickness
in the Portuguese Congo, which have apparently been cured by pro-
longed treatment with Atoxyl, 16 out of 35 remaining in good health
for from three and a half to four years. Either 4 gr, daily or yj gr. twice
a week are injected. He does not mention the occurrence of optic
neuritis. On the other hand, Werner^® failed to save a patient with T.
rhodesiense by atoxyl and tartar emetic injections, this form appearing
to be much more virulent than the Uganda one. The man became
blind, and rivo days before death trypanosomes were easily found in
the spinal fluid.

AV. Kolle, O. Hartoch, M. Rithermundt, and W. Schurmann’^^ have
tested a new compound, Trixidin (30 per cent emulsion of antimony
trioxide in oil), against strains of nagana and sleeping-sickness trypano-
somes. Intramuscularly in doses of i mgram it certainly cures in-
fected mice, and is practically non-toxic. They also found that valuable
results could be obtained by inunction of Metallic Antimony in animals
infected with trypanosomes, which they compare with mercury inunc-
tion in syphilis. They think the antimony may be altered into a more
active substance in passing through the’ skin. This method is now
being tried in cases of sleeping-sickness and trypanosome infections of
animals.

^e^^eences. j\IeiL Jouv, 1912, 99, 1182,’ 'Tvop. jMsd. ct'nd

19x2, 181 ; ^Ihid. 269 ; ^Jottr. Trop. Med. and Hyg. 1913, Jan. ; Kinn.

301 ; ^Ibid. 317 ; Ubid. 1913. 30i ; ^Ihid. 317 ;
Bnt. Med. Jouv. 1912, ii, 1625 ; ^^Proo. Roy, Soc. 1913, B. 2S5 ; Mbid. 269 ;

Med. Jouv. 1913* 9 , 13x5 J Johns Hop. Hasp. Bull, 1913, S3;
jjouy. imp, Med. and Hyg. GGC, 113 ; 1913, Si ; med,

n ccn. 1913, 261 ; '^Ubid. 825.

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MEDICAL ANNUAL

TUBERCULOSIS, CLINICAL PATHOLOGY OP* Oskar C. Gruner, M.D.

The detection of bacilli in the blood-stream has received much atten-
tion during the past year, and different methods have been devised.
Rogers and Murphy^ investigated fifty cases of tuberculosis of different
grades by the Kurashigi-Schmitter method, which consists in adding
I c.c. of blood taken from the arm to 5 c.c. of 3 per cent acetic acid.
The mixture is centrifuged for half-an hour, and the top liquid poured
off, while the sediment is dissolved in 5 c.c. of concentrated antiformin ;

5 c.c. of absolute alcohol are added. The mixture is again centrifuged
for half an hour, the deposit is washed with distilled water, again
centrifuged, and then slides are prepared. — [A large amount of time
is spent in a technical procedure whose value is not substantiated by
the majority of investigators. — O. C. G.]

Bachmeister^ refers to finding tubercle bacilli in the blood of healthy
persons, and insists that this is a manifestation of pseudo-tuberculosis.
The only means of distinguishing the two is by the introduction of
material into a guinea-pig sensitized with a previous dose of tuberculin.
Kahn^ states that the stroma of red cells, even fibrin after treatment
with antiformin, may simulate tubercle bacilli. Frankel,^ G 5 bel,^ and
others adversely criticise the test originally advocated by Rosenberger
in 1909. Brandes and Mace® consider that the fault does not lie with
the facts but with the observers, as they discovered that Bachmeister
used rabbits and not guinea-pigs for his controls ; and in criticising
the interpretation of the red stain of the bacilli, they state that true
bacilli take a red and false ones a violet stain. A very careful study of
the subject, however, was made by de Verbizier,’ who came to the con-
clusion that it was quite erroneous to believe that blood of tuberculous
patients contained bacilli in even as much as a quarter of the cases. The
bactericidal power of the blood serum is adequate even in such patients.

Tubercle Bacilli in Urine. — E. Lowenstein® refers to the important
circumstance that, in a number of cases in which the bacilli appear in
the urine after removal of the testes, they come from the prostate,
even though there are no symptoms of tuberculosis in that organ.

Staining Methods. — Macalister® gives a list of the staining methods
applied to the examination of sputum. He states that Much’s method
is not suitable for routine use, because so many other organisms take
up the stain besides tubercle bacilli. He considers that the remarkable
granular structure of tubercle bacilli is due to some artefact. Herman’s
method, using 3 per cent crystal violet in 95 per cent alcohol mixed
with 3 volumes of i per cent ammonium carbonate as mordant, and
staining with this for a few minutes, washing, treating with 10 per cent
nitric acid and then absolute alcohol, and counter-staining with 3 per
cent chrysoidin, is useful for bringing out metachromatic spore-hke
granules and branching forms. The original Ziehl-Neelsen method is
a long way the best. Horace Wilson,^® however, is very much in
favour of the pier in method, specially for urine. It runs as follows :
Stain with carbol fuchsin, warm, but without too much heat ; pour off
the stain without washing, and pour on picric acid alcohol (consisting

KEW TREATMENT

623

TUBERCULOSIS

of equal parts of saturated solution of picric acid and alcohol) ; after
three seconds wash with 60 per cent alcohol ; treat with 15 per cent
nitric acid till yellow (thirty seconds), wash again with 60 per cent
alcohol, counterstain with picric acid alcohol till lemon-coloured, and
wash with distilled water, and dry gentl}^ at a low heat. The bacilli
are thrown out very conspicuously against the yellow background.
— [One cannot but feel that there is a great amount of time wasted on
other staining methods, considering the absolute soundness of the
Ziehi-Neelsen process, especially as aided by antiformin, by means of
which, in material containing even only two or three organisms, these
are readily secured under the microscope. — O. C. G.]

Leiicocytosis, — Holroyd^^ recommends the examination of the blood
by Avnetlis method {see Medical Annual, 1912). Using the classifi-
cation of leucocytes into five groups with the percentages 5, 35, 41, 17,
and 2 respecti\’eiy, he finds that cases of tuberculosis invariably show
marked increase of the first two groups at the expense of the remaining
three. Analyzing his figures, we find the average to be thus — 32, 40,
23*3, 4, and *7 respectively. The great increase in the first two groups
is the essential feature. As improvement takes place, the deviation to
the left is less marked.

Serum Diagnosis. — The value of complement fixation in tuberculosis
is dealt with by Dudgeon, Meek, and Weir.^- Antigens used are
extract of sputum, tissues, and various tuberculins and tubercle
bacilli. In every case where a patient was under treatment with
tuberculin, the reaction was positive. It was always negative in persons
who were merely in contact with, tuberculous people. Nesfield^^ could
not find antibodies in acute tuberculosis. He shows the relation
between the antibody content and the opsonic index, and he believes
that the leucoc^^te is an extremely delicate test for the amount of
free antibody in the serum,

Faginoli’-^ describes a method of applying Ascoli’s thermo-precipitin
reaction for the diagnosis of tuberculosis of the lungs. The test may
become positive even if the bacillus cannot be found in undoubtedly
positive cases. Roughly, the test consists in mixing sputum with
chloroform, incubating, and then replacing the chloroform by a saline.
The filtrate is then run on to the surface of Vallee’s anti-tuberculous
serum, and after keeping in the incubator for half an hour, a ring
should be formed at the junction line.

References . — ^ Jour. Amer. Med. Assoc. 1913, i, 995; ^Miinch. med.
Woch. 1913, 343; ^Ibid. 345; ^Deitt. med. Woch. 1913, 737; ^Ihid. 1136;
^Ihid. 1137 » "^kev. de Med. 1913, i, 161 ; ^Deut. med. Woch. 1913, 499 ;

Med. Jour. 1912, ii, 411 ; “^Hbid. 413; ^^Ibid. 1913, ii, 927. ; ^-Lancet, 1913,
i, 19: Med. Gaz. 1913, July, 256; '^'>‘Miinch. Med. Woch. 1913. 14S0.

TUBERCULOSIS IN CHILDHOOD. {See also Bronchial Glands ;

Tuberculosis, Surgical.) Frederick Langmead, M.D., F.R.C.P.

Etiology. — Dicidence. — Modem methods of diagnosis by the
specific tests and by A"-rays, more careful scrutiny at post-mortem
examinations, and bacteriological evidence, all tend to confirm the

TUBERCULOSIS

624

MEDICAL ANNUAL

view that tuberculosis is an extremely common disease in children.
As Eric Pritchard^ says : Within the short compass of one hundred
years, a disease almost unsuspected below the age of puberty has come
to be regarded not only as the commonest of all diseases affecting
childhood, but practically as a universal disease among children of the
proletariat classes.” To quote the figures obtained from only a few
areas, Hamburger and Monti, using the tuberculin test in Vienna,
have claimed a tuberculosis incidence of 90 per cent in the case of
school children of 14 years of age, of 70 per cent in children between
the ages of 7 and 8, and of 20 per cent during the third year. In
Diisseldorf, Daske, using von Pirquet's test, found that of children
of 6 to 8 years old, 40*7 per cent * reacted positively ; from 9 to
II years old, 43*7 per cent, from 12 to 14 years old, 49*9 per cent.
Nietner,2 ^ limited area in Germany, the Furstentum Birkenfeld,
obtained positive results in between 26 and 67 per cent of the children
in a rural community, and in one badly affected area, in as many as
87 per cent in the oldest girls’ class. Statistics similar to those of
Hamburger and Monti have been furnished by Mantoux, in Paris, and
by Ganghofner, in Prague. On the other hand, as Pritchard remarks,
though tuberculosis is a terribly fatal disease during the first few
months of life, the mortality rate among those affected rapidly falls to
about 2 per cent at the end of the fourth year. Thus children may be
said to be highly susceptible, but, with the exception of the first tw^o
years of life, little liable to fatal results.

C. Paget Lapage,® working in Manchester, found that among 1000
hospital children, 32 per cent of those 2 years old and under reacted
positively ; the proportion steadily increased as years advanced, and
6o*8 per cent of those between 10 and 14 years old gave a similar
reaction, although 51*2 per cent of those -were free from signs, sym*
ptoms, or a tuberculous history. This was corroborated by x-ray
examination ; 56*6 per cent of the children who showed indefinite
symptoms on clinical examination were found to have intrathoracic
tuberculosis, healed or active, and 26-6 per cent of those free from
signs, symptoms, or history also showed tuberculous lesions. The
disease was nearly always at the roots of the lungs, either the bronchial
glands or lung tissue, and the apices were very seldom affected.

Sources of Infection. — ^Nietner* points out that the cases which arise
by direct hereditary transmission are so few that their significance is
negligible in the struggle against tuberculosis. He recognizes occa-
sional infection by tuberculous milk, but considers that such cases are
comparatively uncommon, and believes them to be especially mild in
character. On the other hand, the united findings of the English
Royal Commission and the Imperial Enquiry in Germany, give bovine
tuberculosis as the form of infection in 33 out of 133 cases, MitchelP
has shown that 90 per cent of the cases of tuberculous disease of the
upper deep cervical glands occurring in Edinburgh are of bovine
origin ; and in 70 cases of bone and joint tuberculosis in children
in the same city, the bovine bacillus was found in 41 by Fraser.®

NEW TREATMENT 625 TUBERCULOSIS

Infection by direct inoculation is a rare event. An unusual manner
in which this may occur is by the ritual of circumcision. Emmett
Holt’ describes a case of generalized tuberculosis in a baby, who died
at three and a half months, in whom the infection arose in this way.
It was very virulent, and the lesions were widespread. Acid-fast
bacilli were found in the sputum of the man who officiated. Tuber-
culous nodules were found in the child’s iliac artery, myocardium, and
skin, as well as in nearly eveiy^ organ in the body. Holt was able to
find references to 40 other cases in the literature. Of the 41 patients,
including his own, 16 are known to have died, 7 are reported as having
partially recovered, in 12 the final results were not stated, and in 6
recovery is said to have taken place. In many of the reports, several
children have been infected by the same operator. As a rule, the earliest
symptoms have been observed in about a week after the operation.
The wound does not heal, but suppuration and ulceration follow.
The early ulcer may be anywhere on the prepuce, but is usually on the
fraenum. It may remain as a local condition or become generalized.
By the second or third week the inguinal glands enlarge, and in many
cases break down, with abscess formation. Early removal of these
glands would appear to hold out the best hope of checking the infection.
Most of the cases were diagnosed at first as syphilis.

Hess® records an interesting group of ten infants, varying in age
from about two to three years, who were apparently infected by a
tuberculous attendant. They were all in one ward, and were in charge
of the attendant from May 15th to July ist, 1912. All had been
tested by von Pirquet’s method in April, and three had given a
positive reaction. About the middle of July, soon after the nurse
left, all were tested again, and reacted as before. In October all
gave a positive reaction, and also again in the following January.
No tuberculosis could be demonstrated by clinical examination,
however.

Site of the Primary Lesion . — Opinions differ as to the primary focus
of the disease in children. Most English observers would agree with
Pritchard,^ who holds that the lymphatic glands are the seats of election.
He suggests that those in the drainage area of catarrhal or otherwise
diseased organs constitute zones of special danger, and that tubercle
bacilli become arrested in them, whether brought directly or previously
filtered through other glands. The experience of most writers agrees
with that of Still, who found the thoracic glands far most commonly
affected. Pritchard, however, considers that the abdominal and
thoracic glands are diseased with equal frequency ; and Lapage, at
the Manchester Children's Hospital, found that the abdominal glands
are affected often more than the thoracic glands, in 'the ratio of 71 to
55. Nietner states that the consensus of opinion inclines more and
more to the theory that usually it is the lung that is the primar}^ area
of infection, an opinion which is supported by Ghon, of Prague, who
found this so in 95 per cent of 184 post-mortem examinations.
Mitchell^® investigated the tonsils in sixty-four consecutive cases of

TUBERCULOSIS

626

medical annital

children suffering from tuberculous disease of the upper deep cervical
glands, and found evidence of tuberculosis in 39 per cent.

Diagnosis. — ^The great disproportion between the incidence of
tuberculosis in children as tested by tuberculin reactions and seen post
mortem, and the frequency of its recognition clinically, is sufficient

indication of the difficulty of its detection at this age. Thus, as

Pritchard says, infants may be “ riddled ” with tubercles, and older
children may have severe disease of the mediastinal or peritoneal
glands, without exhibiting any serious impairment of health or
constitutional symptoms. Wasting is not an essential feature until
the disease is far advanced, although infants, as a rule, come to a
standstill, and fail to put on weight in spite of careful dieting.
The temperature shows irregularities, but scarcely ever such wide
variations as are seen in adults. Sweating is a common S3nnptom
in this as in many other childish complaints, but he places some
reliance on it if it occurs in older children. General lassitude, a

poor appetite in the morning, and buoyancy of spirits alternating

with periods of depression, all suggest tuberculosis. For evidence
of enlargement of glands, all areas accessible to palpation should
be examined. He lays stress on the presence of enlarged axillary
glands, the swelling of which cannot be explained on other grounds.
Cervical glands are enlarged from so many local causes that they
do not provide so useful an indication. Since enlarged medias-
tinal glands are so frequently present in tuberculous children, it is
essential that this region should be investigated by every possible
means. Pritchard gives the following as the more common signs and
S3nnptoms of tuberculous adenitis in this situation ; (i) A hollow
spasmodic cough, without expectoration or obvious cause ; (2) Im-
pairment of resonance, especially to the right of the sternum at the
level of the second intercostal space in front, and the interscapular
region behind ; (3) Enlargement of the superficial veins in the upper
third of the chest, especially when unilateral, on the right, and radiating
from the coracoid process to the sternal end of the second intercostal
space ; (4) Inspiratory stridor heard universally over both lungs, due
to pressure on the trachea (StiU) ; (5) Defective entry of air into one
lobe, due to pressure on the bronchus ; (6) A bruit at the inner end of
the clavicle on forcible extension of the head (Eustace Smith) ; (7)
Pleuro-pericardial friction rub (rare) ; (8) Tracheal character of the
voice heard on auscultation below the usual level of the seventh cer-
vical spine behind (d'Espine) ; (9) Evidence of skiagram, distinct in
advanced cases, unreliable in recent. Tuberculous glands in the
abdomen are usually undetected during life ; they are most often
recognized in the fight iliac fossa or to the left of the vertebral column
at the level of the umbilicus,

A. G. L. Reade and F. G. Caley^^ emphasize the value of X-rays in
the diagnosis of tuberculosis of the mediastinal gland or commencing
at the pulmonary root. It is often argued that opacities are frequently
seen in this situation, and have no special significance ; but these

NEW TREATMENT

TUBERCULOSIS

627

writers are convinced of their pathological import. They examined a
series of control children of about the same age, who were in good
bodily health, and failed to give a positive von Pirquet reaction, and
in them no opacities were seen. The shadows seen in those who reacted
positively to the test consisted either of linear striation corresponding
to the larger bronchi, or of an indefinite mottling, or showed a more
definite circumscribed outline.

In proportion to the number of cases in which pulmonar^^ tubercu-
losis is found post mortem in one situation or another, the number in
which it is diagnosed during life is very small. Yet it must be remem-
bered that when advanced clironic disease is discovered clinically it is
most often not tuberculous. As P. L. Sutherland and A. A. Jubb^‘^
point out, it is more often due to chronic catarrhal conditions, associated
sometimes with varying degrees of bronchiectasis, and is the chronic
residue of pneumonic or bronchopneumonic inflammation, which in
turn has followed measles or whooping-cough, or may have arisen
ie novo. Where dullness is elicited in such cases, it is no doubt due to
fibrosis. They base their opinion on the negative results which attend
examination of the sputum.

The one certain proof of active tuberculosis, namely, the discover}^ of
tubercle bacilli, often proves a broken reed in the case of children, for
the lesions do not commonly communicate with the bronchi, and even
in definite pulmonary disease, sputum is not often obtainable. Hence
the amount of reliance to be placed upon iuherculin tests is a matter
of considerable moment. It is clear, from the great frequency with
which a positive reaction is obtained, that such a reaction can help us
very little, except in infants, in determining -whether the particular
illness from "W'hich the child is suffering is due to tuberculosis or not.
A negative reaction is of greater value, for by it, with certain reserva-
tions, tuberculosis may be excluded. Lapage^^ places great reliance
on Von Pirquet’s test. In his opinion, although the subcutaneous
method gives the highest percentage of results, this cutaneous method
is the more suitable. A reaction indicates that the subject has been
infected, but does not mean that the disease is progressive or active.
A marked reaction in a healthy person may be of good import, and
need not bear a sinister interpretation. A negative result may follow
the test in children infected with tuberculosis ; (i) If the disease is
advanced ; (2) If there is cachexia ; (3) In very acute disease ; (4) In
mixed infections, or cases complicated by acute disease. A single
negative test does not exclude -tuberculosis, for on repeating it, the
percentage of positive results increases by as much as 28 per cent.
Even a repeated negative result does not exclude tuberculosis, for
some definitely tuberculous patien-ts react on the third attempt, and
others fail to after several -trials.

Treatment. — Preventive , — Pritchard dwells on the importance of
prophylaxis, more especially in the first -two years of life, the period
-when the disease is most dire. The tw'O factors of greatest moment in
successful prophylaxis are protection from sources of infection and the

TUBERCULOSIS

628

MEDICAL ANNUAL

maintenance of strength. The most essential step is to remove young
infants from an environment of open infection. Damage to the
lymphatic system, by affording seats of diminished resistance, enhances
the chance of a serious tuberculous invasion. Thus, all factors which
predispose to catarrhs predispose also to tuberculosis ; such are con-
finement indoors, ill-ventilated rooms, dust, excessive clothing, and
too much warmth. As a protective measure against catarrhs, he
recommends the graduated cold bath, the temperature of which is
gradually reduced from 100° F. by one degree daily, until it is given
almost cold. He advocates a varied and liberal proteid diet, whether
the infant is breast- or bottle-fed, and supplements the milk diet mth
feedings of raw meat juice, yolk of egg, plasmon, and other easity
digestible forms of albuminous food.

After the second year of life, our energies, he says, should be directed
towards supporting the strength during convalescence from measles,
whooping-cough, chicken-pox, and scarlet fever. At such times
removal to the sea, or to bracing country air, is one of the most satis-
factory and economical measures. This is urgently needed when
these diseases follow each other in rapid succession with no period
intervening for convalescence.

Nietner argues that since it has been demonstrated that the milk
of tuberculous mothers, even when there is no evidence of mammary
disease, harbours tubercle bacilli, the suckling of infants by such
mothers should in all circumstances be prohibited. Cow’s milk, in his
opinion, should always be boiled. Like other workers, he banns the
comforter, and the evil habits of kissing babies on the mouth, or
washing their faces with the maternal pocket handkerchief, moistened
or not as the case may be with saliva. Infection through school
attendance he regards as negligible, but he attaches more importance
to the possibility of infection by the teacher, urging that a thorough
medical examination should be made of all candidates, and that all
those found to be tuberculous should be rigidly excluded.

Cumtive . — Nietner holds that the curative treatment is based on
hygienic and dietetic methods, supplemented by the administration of
Cod-liver Oil. Concerning the value of Tuberculin there is more
difference of opinion. Pritchard thinks that tuberculin has a very
limited usefulness, and is uncalled-for in the great majority of cases.
Nietner, on the contrary, states that the only cases which should be
excluded from this treatment are those of children who have already
reached the more advanced stages of pulmonary disease. Recommend-
ing small doses to begin with, he, nevertheless, thinks that there is at
present a greater danger of giving too small doses which are ineffective,
han too large which are toxic. A new method of treatment introduced
by Finkler, of Bonn, that of using Methylene Blue and various Copper
Salts, and administering them by subcutaneous injection, by internal
application, and by inunction, is too recent for criticism.

References. — ^Pract, 1913, i, 2S0; ^La 7 icet, 1912, ii, 1343 ; Med.

Jour. 1912, ii, 1375 ; ^Lancet, 1912, ii, 1343 ; ^Quoted by H. J. Stiles, Trans.

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629

TUBERCULOSIS

xvii. Internat. Congr, Med. Sect. x. ; ^Jour. Exp. Med. 1912. xvi, 4 : '^Jour.
Amer. Med. Assoc. igi 3 > ii 99 ; 1617: ^Pract. 1913, i, 280; ^oQuoted

bv H. J. Stiies. Trans, xvii, Internat. Congr. Med. Sect. x. ; '^Mancet, 1912,
ii' 1501 ; ^-Brit. Med. Jour. 1913^ L 1156; Brit. Jour. Child. Dis. 1912,

493. 332.

TUBERCULOSIS, LARYNGEAL. [See Larynx.)

TUBERCULOSIS, PULMONARY. J. J. Perkins, M.B., F.R.C.P.

Diagnosis. — Fishberg^ calls attention to a point which has become
specially important in recent years owing to the search for earty tuber-
culosis, namely, that abnormal signs at the apex may have some
other cause than the tubercle bacillus. He classifies the conditions
other than tubercle, which may lead to apical lesions in three groups :
(i) Collapse induration, found chiefly in mouth-breathers ; (2) Apical
catarrhs after influenza, in the emphysematous, or in those who follow
dusty occupations ; (3) Apical indurations found in persons with

heart lesions. Of these three groups, the first is the most important
and the most frequent. One apex, usually the right, is dull and
retracted, with harsh and even bronchial breathing and crepitation ;
the history is one of long-continued nasal obstruction and mouth-
breathing, with frequent catarrhal attacks, and profuse expectoration,
which may even be streaked with blood. The general health, how-
ever, remains fairly good, and the patients are able to continue their
work, the condition often being discovered by accident. In the
mouth-breather, owing to the lack of filtration, inspired dust can
of course be carried into the apex of the lung, exciting repeated attacks
of catarrh, follow’ed by fibrosis and contraction ; or the induration may
follow^ on atelectasis without any inflammation. As regards the
difierential diagnosis from tuberculosis, points are : the history of nasal
obstruction and colds, the absence of tubercle bacilli from the sputum,
even on repeated examination, the absence of fever and tach^xardia,
and above everything, the comparative excellence of the general health,
and the absence of the fatigue and languor of the tuberculous and
of persistent loss of wxight. It has long been knowm that the com-
bination of disease of the left heart with tuberculosis is uncommon ;
yet cases of mitral disease are frequently mistaken for phthisis, and
abnormal signs at the apices are often found. In six months Fish-
berg examined 38 patients suffering from mitral disease, 27 of
wLom showxd signs suggestive of tuberculosis at one or other apex ;
22 showxd crepitation or rhonchus of some kind ; 5 gave a history
of blood-stained expectoration, and i stated that he had a profuse
haemopt^'sis. It is evident from these figures that one should be very
careful in diagnosing phthisis in the presence of a cardiac lesion. In
fact, w'hatever the physical signs in the lung, one should accept
no evidence as positive except the presence of tubercle bacilli in
the sputum. Of course this group, like the pre\nous one, wall as a rule
fail to show^ the general or constitutional symptoms wLich are so
marked in tuberculosis.

Stoll^ reminds us that wx are too apt to think of tubexxulosis as a

TUBERCULOSIS 630 MEDICAL ANNUAL

disease of young adults. It is true that nearly one-third of those who
die are between 15 and 40 years, but these figures give no idea of the
relative importance of tuberculosis as a cause of doatli at any one
period. Estimated on the basis of persons living, the percentage of
deaths from tuberculosis is twice as high at 65 as between 15 and 20.
Pulmonary tuberculosis is apt to be overlooked in the aged because
its symptoms are peculiar, and because, on the other hand, chronic
bronchitis and emphysema are so common in the elderly. In them,
cough is the chief complaint, and other symptoms of tuberculosis are
frequently slight and in abeyance for long periods. In sixteen people
over 60 who came because of cough, Stoll found seven to be undoubtedly,
and two possibly, suffering from tuberculosis. He quotes details of
several cases in which infection had taken place many years before,
and remarks that the mere fact that a cough has been present for a
number of years is too often taken as a sufficient proof of its 11011-
tuberculoiis nature. From his description it is evident that in several
of his cases the bronchial glands were much enlarged from tuberculosis,
and he finds great help from the presence in the aged of ‘D’Espinc’s sign,
the value of which, thei*efore, is evidently not confined to childhood
{see Bronchial Glands, Tuberculosis of). Though chronic in its
course, Stoll holds that an acute extension, too often taken to be acute
pneumonia, is not infrequently the cause of death.

In this connection, Jex-Blake’* calls attention to the frequency with
which the word “ influenza is used by tuberculous patients. During
the last three or four years he has carried out inquiries among his out-
patients at the Brompton Hospital to gather light on the meaning of
the term, and believes that in many cases the so-called influenza means
an attack of acute bronchitis set up by some microbe other than B.
injluenzcB \ and that in many more, ‘'influenza” really means an
acute tuberculous infection of the lungs. The former question does
not concern us here, but it is interesting to note that in many
countries the bacillus of influenza is no longer to be found, and when
jiresent in the sputum may be simply a saprophyte, rnman, examining
the sputum of 16 cases of chronic bronchitis, found the pneumococcus
in all, Fricdlander’s bacillus in 8, Micrococmis catmrhalis in 3,
and a staxihylococcus in i. As regards sporadic cases of influenza,
Kuhemann in 1905 could find B. in only 36 out of 73

cases, even though these had been diagnosed clinically as influenza.
Consequently, many bacteriologists advise that the term ” influ-
enza ” should be used in a purely clinical sense. Evidently many
of the attacks which pass under the name of influenza, at any
rate when the term is vaguely used by the laity, must be due to the
invasion of some other organism. Nor is the bacillus of influenza to
be found at all commonly in the sputa of the tuberculous. For example,
Inman, examining the sputum of loi patients with pulmonary tuber-
culosis, failed to find Pfeiffer's bacillus in a single one. What a contrast
between these figures and the statements of the patients themselves !
Among 416 cases of pulmonary tuberculosis examined by Jex-Blake,

NEW TREATMENT 63I TUBERCULOSIS

only 152 failed to give some history of influenza. Among the remain-
ing 264, 1 12 stated that their illness began with an attack of influenza,
and 122 that they had had one attack or more of influenza after the
tuberculosis had declared itself. In thirty cases they left it uncertain
which of the two complaints came first. These were all patients, it
must be remembered, seen in recent years, long after the great
epidemics of undoubted influenza had passed away. It is very
generally stated that influenza predisposes to tuberculosis of the lungs,
but our author’s figures makes it reasonable to suppose, as he says,
that influenza is more often tuberculosis. Fever, headache, general
pains, and prostration are symptoms common to the two diseases. Of
course, the possibility of secondary infection compels one to admit that
the invasion of other micro-organisms may be the cause of these inter-
cuxTent febrile attacks ; but in most instances the symptoms wnll be
found to have their origin either in the sub-acute invasion of early
tuberculosis or in an exacerbation of the existing disease.

Regarding the importance of taking a careful history in doubtful
cases of early tuberculosis, Cruice'^ contributes a paper based upon an
analysis of the after-course of all the cases attending at the Phipps
Institute from Jan. ist, 1907, to Feb. ist, 1908, 163 in number, which
were diagnosed as non-tuberculous. He was able to get reliable
information of 50 only. Of these, 16 could be said to be non-tuberculous,
23 were undoubtedly tuberculous, and 1 1 had died, 4 of them from
tuberculosis. In analyzing the history of these 50 cases, he divided them
into two groups : the tuberculous, living or dead, and the noii-tuber-
culous, living or dead, 27 in the former group and 23 in the latter. The
first conclusion he draws is the importance of going thoroughly into
the history of exposure to infection, which should include not only the
patient’s immediate family, but his intimate associates. Too often
such an inquiry is purely perfunctory, and the patient’s mere “ Yes ”
or No ” accepted as final. He insists, also, that a cough that has
lasted for two months or more, and cannot be explained by the presence
of some general or local condition, should be looked upon with grave
suspicion. Hasmoptysis, sometimes considerable, was pi'esent in a
number of these cases; in 11 of the first group and 4 of the second.
Cruice holds it a safe working basis to regard all cases of hemo-
ptysis as of tuberculous origin until proved otherwise. Strieker, who
investigated goo cases of haunoptysis occurring in the Prussian army,
concluded that soldiers attacked with haemoptysis without special
cause are in at least 86 per cent tuberculous ; in the cases in which
the hsemorrhage follows the special exercises of military service, about
75 per cent are tuberculous, while in the cases which come on during
swimming or as a consequence of direct injury to the thorax, about
one-half are associated with tuberculosis. Dyspnoea was present in
both classes, as were night sweats, loss of weight, fever, and pleurisy ;
but the fact that a number of those who showed these symptoms did
not develop definite tuberculosis later must not be taken as under-
valuing the significance of these signs,

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632

MEDICAL ANNUAL

Not all cases even of definite and active tuberculosis run a prolonged
course, Fisliberg*^ thinks it not unreasonable to suppose that tuber-
culosis, like other infectious diseases, occasionally runs an abortive
course. He defines the abortive type as covering cases whose course
is characterized by short duration, one to three or four months, and
which invariably recover even without special treatment. The specific
level’s are well known to abort, and on the other hand, from the number
of people who are found after death to have signs of healed tuberculosis
in the lung, it is clear that we should be able to trace the process in
life. Neisser and Brauning have coined the term “ tuberculosoid ”
to describe this class ; and that it is not rare is shown by the fact that
among 1900 persons who were treated at the Breslau clinic during ten
years, 300 examples of this condition were found, examination from
four to ten years later showing that they w^ere nearly all well. Such
cases, then, are those in which the lesion is circumscribed, of little
activity, and quickly healing. Many of them are not diagnosed during
life, their symptoms passing as “ colds,” though others, beginning with
hiemorrliages. can be recognized. It is evident, therefore, as Fishberg
says, that w’e must to some extent reconsider our picture of tuberculosis
and its prognosis. When he started work’^twclvc years ago as
physician to the United Hebrew Charities in New York, he expected
to see every consumptive succumb within a few^ months, unless vigorous
measures W'ere taken to check the disease and change the mode of life.
As time passed on, he was impressed with the large number of tuber-
cular patients who for various reasons were not admitted to sanatoria,
but continued in their unhealthy surroundings, and who yet held their
own for years. In many instances patients, recommended for
sanatoria, lost their signs and symptoms while waiting for admission.
Many of them had kept at work the whole of this time and had received
no medical care. The following cavsc, one only amongst several, may
be taken as typical. A woman, aged 27, consulted h'islibcrg for
hjemorrhage two weeks before, three similar profuse luenxorrliages
having occurred dxiring the previous five years. Cough, fever, malaise,
night swccits, etc., were present, and 7 lb. weight had been lost within
two weeks. The physical examination showed dullness, bronchial
breathing, and crepitation over the right upper lobe, witli tubercle
bacilli in the sputum. With rest in bed for two weeks, the fever ceased
and her general condition much improved. This improvement has
continued during the last fifteen months, cough has ceased, and the
patient has gained 18 lb. in weight. Other cases are reported which
began with sharp continued haemorrhage, though Fishberg believes
this is not true of the majority. Tubercle bacilli, as one might expect,
are scanty among such cases, appearing only occasionally. Indeed, in
quite a number they have been absent altogether, though physical
signs, typical of tuberculosis, have been present. Whether the benign
course of these cases is due to the exceptional resistance of the patients,
or to infection with an attenuated strain of organism, cannot be
determined.

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633

TUBERCULOSIS

Mitchell Bruce asks : how is one to recognize these benign cases
with their favourable future, at the time when one sees them. The
family history is of importance in his eyes, for if the tuberculosis has
been directly inherited, it will run a less favourable course. More
important, perhaps, is the patient’s appearance and individual con-
stitution. In taking his case, Bruce lays particular stress on the past
history of the illness. The patient may discover to us a history of
tuberculosis in other parts of the body, such as the glands or peri-
toneum, from which he has recovered ; indeed, we may. ascertain
that the lungs themselves have been affected years before, and that
the case is one of recrudescence after long quiescence, and not one of
incipient phthisis at all. The proof of recovery from active tuber-
culosis in the past serves as a reasonable indication of the patient’s
capacity to recover again.

Discussing many of the points which have been raised in previous
paragraphs, and especially the importance of taking a careful history,
both family and personal, Bruce quotes, as an example of the value to
be obtained by this means, a case of bronchial catarrh with no more
than suspicious signs at the apex, in which it turned out on enquiry
that the father, the mother, and two sisters had all died from tuber-
culosis, As he says, practical men do not make light of facts like these,
however doubtful the physical signs and however unsettled the doctrine
of inheritance of tuberculosis. Haemoptysis is one of the events one
meets with in taking such a history, occurring perhaps years before,
and disregarded. Very frequently, in such cases, physical signs are
absent and may be so for some time, and one should not be led on that
account to undervalue the danger. After a variable interval of months
or years, active disease makes its appearance ; as Bruce says, the

conclusion is irresistible that such cases were tuberculous from the

first. He gives, as an example, a man of 24 who had had a haemoptysis ;
there were no physical signs in the lung ; twelve months later, more
than one large bleeding took place, still with no signs of the disease in
throat or chest. Twelve months later still, haemoptysis occurred again,
and now bacilli were discovered in the sputum. A few months after-
wards there wove ordinary signs of disease at the right apex.

As regards the significance of pleurisy, Bruce allows that the

percentage of cases in which an attack is followed by pulmonary

tuberculosis is variously estimated by different observers. According
to Clifford Allbutt, ^ it is safe to say, from a review of a large number
of the statistics open to us, that of all “ idiopathic ” pleurisies in
persons, say, over five years of age, 50 per cent are tuberculous. As
regards child life, he holds the incidence to be not more than one in
ten, but, on the other hand, he has remarked that in elderly persons
pleurisy is often tuberculous. The figures he quotes may be taken
as authoritative, but the matter is evidently one on which much
difference of opinion exists. It is safer to use with Bruce the indefinite
term, “ large percentage,” for whether the pleurisy is ” latent ” or marked
by severe pain or effusion, it is too frequently followed by disease of

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MEDICAL ANNUAL

the lung, at an interval which varies widely from a few months or even
less to twenty years. Examples of the interval quoted by him from
cases of his own are three, Eve. eight, twelve, fifteen, and twenty-one
years. The truth of this sequence has only been recently established,
and is still very readily overlooked. The treatment which he adopts
for these incipient cases is twofold ; some he sends to sanatoi'ia, others
are allowed to continue treatment in their own homes, but those who
are not sent into a sanatorium are still distinctly informed that they
are to regard themselves as subjects of tuberculosis, and must submit
to home sanatorium life and other methods of treatment for the
disease.

Treatment. — {See also Lung, Surgery of ; Pneumothorax, Arti-
ficial ; Tuberculin). Bardswell,® reviewing the cases treated during
the four years from 1907 to 1911 at the King Edward VII Sana-
torium, states that during that time 764 cases were admitted in
whom tubercle bacilli could be found. Dividing these cases into
the usual groups, (i) early, {2) moderately advanced, and (3) advanced,
he finds that 83*6 per cent of those in group i arc well or alive ;
61 *6 per cent of those in group 2; only 28*5 per cent, in group 3,
as might be expected. The ]proportion of patients who lost their
bacilli after an average of four months’ sanatorium treatment is only
20*6 per cent What this means is shown by the further figures,
that of the 15S patients who lost their bacilli, S.pT per cent arc
well or alive, while of the remaining 606 discharged with tubeixle
bacilli still present, only 50 per cent are well or alive. It is very
encouraging, as he states, to note that the patients with well-marked
disease (group 2), who lose their tubercle bacilli, have quite as
good a prognosis as the slight cases (group i) under the same circum-
stances. Of 79 cases in group i who lost their tubercle bacilli, 87-3 per
cent arc well or alive, and of 64 cases in group 2, 90’6 per cent. It is
evident, then, that in our treatment wc should be satisfied with nothing
less than disappearance of the bacilli, 'fhe reeprds rcvie\vcd by him
are those of cases under pure sanatorium treatment:. They are not
perhaps as satisfactory as might be hoped, especially with logard to
group 2. Eminent German physicians have found the combination of
Tuberculin with Sanatorium treatment much more effective in clearing
the sputum of bacilli than sanatorium treatment alone. It is to be
hoped that the experience of the King Edward VI 1 Sanatorium,
which is now entering on a period of observation of the results of
tuberculin, will be found to confirm this view.

McDuffie® has exhausted almost all the known methods of treatment
in the effort to find some means of relief for very advanced cases. His
experience seems to have been completely disappointing, until he
tried the injection of a mixture of Sodium Salicylate and Guaiacol
according to the following formula : sodium salicylate 37-5 per cent,
guaiacol 12-5 per cent, glycerin 50 per cent; used in 50 gr. doses in
220 c.c. of sterile water, by intravenous injection. Profuse perspiration
follows the injection, and with the sweating comes a,melioration of all

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^35

TUBERCULOSIS

the symptoms ; the appetite improves, dyspnoea is much relieved, and
the general condition becomes more lifelike. The blood analysis, the
weight, pulse, and respiration also show signs of improvement, and
the' temperature is frequently reduced to normal after four or six
injections, while the death-rate falls from 62 per cent to 31 per cent.
He regards this mode of treatment as undoubted^ the quickest and
most satisfactory of all the methods he tried for cases of secondary
infection and advanced disease. He attributes much of the benefit
to the elimination of toxins by the profuse sweating.

Reeve^^ has tried the treatment of phthisis by the intensive Nascent
Iodine method (Curie) in the phthisis ward of a large Poor-law
infirmary. No selection of cases was exercised, and when one remem-
bers the class of case which finds its way into the Poor-law infirmary,
it must be said that the test is an exacting one. Of his cases, 72 per
cent were over the age of 40, 90 per cent were said to have a past
history of alcohol, and a large percentage one of syphilis. His method
shows a iew slight alterations from Curie’s owm practice ; 30 gr. of
potassium iodide are given in half a pint of water at 7 a.m. ; four
hours later, i oz. of free chlorine water is given in half a pint of lemonade.
This dose is repeated at two-houiiy intervals until enough has been
given. At first; 3 oz. of chlorine water are administered daily,
and at the end of three weeks the dose is increased to 4 oz. and
later to 5 oz. The signs of iodism are produced, cold in the head
and headache, but in only two cases were these symptoms severe.
On examining the urine, iodine was found to be present in all patients
the following morning. At first the chlorine water caused some
vomiting, but this disappeared when it was given between meals. A
striking improvement in cough and expectoration was noticed, the
purulent character gradually changing to mucoid, and the quantity
diminishing on the average from 4 oz, in the twenty-four hours to
E drachm. About the third week blood appeared in the sputum, and
there were nine cases of luemoptysis, but not sufficient to cause
intermission of the treatment In a number, a considerable gain in
weight followed. As regards temperature, there was an initial rise
in nearly all cases, but after a week the daily remission showed a fall
which continued in most cases until the normal was reached. Various
skin diseases, e.g., acne and lupus, were cured or greatly benefited by
this treatment, and three cases of surgical tuberculosis with open
sinuses showed much improvement.

Flandin^^ has transferred to the treatment of pulmonary hmnorrhage
the nse of Emetine, introduced by Rogers for tropical abscess of the
liver and amoebic dysentery, and claims the same brilliantly successful
results. He had been struck by the immediate disappearance of blood
from the motions in dysentery and from the pus of hepatic abscess
under this treatment, A solution of 0*04 cgrani of emetine hydro-
chloride in T c.c. of distilled sterile water is made and injected sub-
cutaneously. Others have u.scd the same treatment in the same
dosage. The results have been apparently successful, except in one

TUBERCULOSIS 636 MEDICAL ANNUAL

case of very profuse haemoptysis. The method is evidently free from
danger, and certainly worth a trial.

References. — ^N.Y. Med. Jour. 1913, ii. 14 ; ^Bost. Med. and Surg.
Jour. 1912, ii, 291 ; ‘'^Lancet, I9i3> i. 1787; ^Med. Rec. 1912, ii, 334; ^Ibid.
1913, i, 921 ; ^Lancet, 1913, i, 591 ; "^Jbid. 1912, ii, 1485 ; ^Ihid. 1913. h 679 ;
^N. y. Med. Jour. 1913, i 551 ; ^^Pract. 1913, ii, 391 ; ^^Presse Mid. 1913, 779.

TUBERCULOSIS, RENAL. (See Kidney, Surgery of.)

TUBERCULOSIS, SURGICAL. Priestley Leech, M.D., F.R.C.S.

Etiology. — Stiles^ returns again to the question of a more thorough
control of the milk svvpply as being a factor of the greatest importance
in combating surgical tuberculosis in children. He thinks Koch and
his disciples committed a serious error in practically disregarding cow’s
milk as a source of infection in children. From researches carried on
from material obtained at the Royal Edinburgh Flospital for Sick
Children, Fraser and Mitchell came to the following conclusions : In
67 consecutive tuberculous bone and joint cases the bovine bacillus
was present in 41 (61 per cent) ; the human bacillus in 23 (34 per
cent) ; while both types were present in 3. Forty-one of the children
were under four years of age, and in these 78 per cent were due to
the bovine bacillus. In cases where the bacillus was of the human
type, there was a history of phthisis in at least one member of the
family in 71 per cent of the cases. The bovine bacillus was the organism
found in all the children under twelve months old, and each of these
had been entirely nourished on cow’s milk. Of 12 children between
one and two years of age, 8 ow^ed the disease to the bovine bacillus,
and all had been brought up from birth on cow’s milk. In none had
the milk been sterilized.

In 72 cases of tuberculous cervical glands operated on during the
past two years, Mitchell found that in 65 (go per cent) the disease was
due to the bovine bacillus, while in only 7 (10 per cent) was it caused
by the human bacillus. This gives a far larger proportion of bovine
infections than has been found by other observers, but the clinical
histories support the pathological findings. Out of 72 cases, 38
occurred in children under five years of age, and all but 3 were cases
of bovine infection. The maximum incidence occurred in the second
year, and it was found that 84 per cent of the children under two
years of age had been brought up since birth on raw cow’s milk.
Practically half the cases came from rural districts, where, as is w^ell
known, there is little or no veterinary inspection of cows. In 65, cases
infected with the bovine bacillus there was not a single one in which a
history of pulmonary tuberculosis could be obtained in the family. In
14 cases, however, one or more of the other children suffered from some
form of surgical tuberculosis, and here evidence pointed strongly to
infection from the milk supply. In the 72 cases there were only
three instances in which a history of pulmonary tuberculosis could
be obtained in the parents.

In 51 of the cases, the tonsillar lymphatic gland was the first to

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637

TUBERCULOSIS

become infected, and in 44 the posterior as well as the anterior group
of glands were involved. In examining 64 consecutive tonsils in
children suffering from tuberculous disease of the upper cervical
glands, evidence of tubercle was found in 39 per cent. In 30 per cent
positive results were obtained by inoculating guinea-pigs ; in these
the bovine organism was isolated in 12 cases, and the human in 3.
The hypertrophied tonsils of 90 children without clinical evidence of
glandular enlargement were examined, and 6*5 per cent of these gave
microscopical evidence of tuberculous disease, while 10 per cent gave
positive ‘results when inoculated into guinea-pigs, Nathan Raw’s
hypothesis that all surgical tuberculosis is of bovine origin cannot be
admitted, as Fraser found that 38 per cent of the tuberculous bone and
joint cases contained the human bacillus ; and in 71 per cent of these,
one or other parent suffered from pulmonary tuberculosis. These
results ought to induce the medical profession to insist on the use of
sterilized milk for the feeding of infants.

Fraser^ records in extenso the experiments referred to above. The
results give a much greater preponderance of cases infected by the
bovine bacillus than those previously published by other authors.
This is mainly due to the fact that the patients were all under twelve
years of age, and the identity of the organism was established by sub-
mitting it to the following five tests : (i) The cultural characters ;
(2) The morphological appearance ; (3) The distinctive growth upon
glycerin-egg medium ; (4) The reaction upon glycerin bouillon ; and
(5) The result of rabbit inoculation. Of 25 cases brought up on human
milk, in only 6 was the bovine bacillus found ; the remaining 19
were infected with the human bacillus. These are important results,
and should be studied by all interested in checking the spread of
tuberculosis.

Treatment. — Hawes,® of Boston, U.S.A., describes an outdoor
clinic for cases of surgical tuberculosis. He uses Tuberculin (a bouillon
filtrate). While not responsible for all the good results, it is a
factor for good in most cases. The patients are taught the value of
good food, fresh air, etc. He laments the want of institutions for the
treatment of surgical tuberculosis in America. The same lament was
made in the adjourned discussion on Fraser’s paper on bone tubercu-
losis.^ It was stated that there were only two in this country, one near
Liverpool and another in the South of England ; while at Berck-sur-
Mer, near Boulogne, there were five, three with 1000 beds each, and
two with 2000 beds each.

Tubby® outlines a scheme for the treatment of surgical tuberculosis
in children by means of seaside and country treatment in fresh air and
sunshine, and regards this as the best means of combating the disease.
The opinion is gaining ground that for tuberculosis in children the
urban hospitals are unsuitable, and that better results are obtained
by letting the children be exposed to sunshine and fresh air as much
as possible. Jones,® of Liverpool, says the principles of treatment
on which he relies are : (i) Complete physiological Rest ; (2) Good

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MEDICAL ANNUAL

Nourishing Food, special importance being attached to butter, dripping,
jam, and sugar, with an unlimited allowance of good milk ; (3) Fresh
Air and Sunshine. Children under fifteen years of age possess a very
high degree of natural immunity, and operation in joint and bone
disease is rarely necessary, except in advanced and neglected cases.

Lovett and Fish" record the general results of the Massachusetts
Hospital School for Crippled and Deformed Children at Canton, and
say that what may be formulated with regard to the effect of Out-door
Air on children with surgical tuberculosis may be applied to the dis-
tinctly larger field of its efiects on children in general, and probably on
adults as well. Their conclusions are as follow : That even in the
winter climate of New England, living in outdoor air is not attended
with risk of exciting respiratory troubles, frost-bites, or pneumonia ;
coughs, colds, and sore throats are much less frequent than among a
group of healthy boys who do not live wholly out of doors. Infectious
disease has not spread among the children as early as would have been
expected. After admission, weight increases faster than in normal
children, and haemoglobin also increases. Symptoms of auto-inocula-
tion, as shown by increased pyrexia, are as a rule absent, and, in the
opinion of the authoi's, the power of I’esistance and repair improves
under these conditions.

Richard and Felten-Stoltzenberg® report the results of Sun Treat-
ment by the sea in surgical tuberculosis and tuberculosis of the bron-
chial glands. They consider that heliotherapy will give as good
results at the seaside as in high mountains. They conclude, from the
study of their cases, that heliotherapy is a real advance in the conserva-
tive treatment of surgical tuberculosis, and can be carried out at the sea-
side with the best results, as in addition to sunshine, a sea climate offers
other valuable advantages. The treatment should, however, be
carried out in carefully chosen places, in buildings specially built, and
the patients should be under surgical care. Alkan® thinks more could
be done in the large cities in the treatment of bone and joint tubercu-
losis by sun rays ; and Oppenheim^® recommends the use of X-rays
where cases cannot be treated by sunlight.

References. — Med. Jour. 1913, ii, 370 ; ^Ibid, i, 760; ''^Amer. Jour.
Med. Sci. 1913, ii, 10; ^Lancet, 1913. i, 534; ^Ibid, ii, 137; ^Pvact. 1913. i,
182 ; ’^Bost. Med. and Suvg. Jour. 1913, ii, 145 ; ^BerJ. klin. Wocli. 1913^
1062 ; ^Ihid, i. 1434 ; '^^Ihid, 1433.

TYPHOID FEVER. E. W. Goodall, M.D.

Etiology. — Though it has long been known that milk is a vehicle
by which the B. iyphosiis can be disseminated, yet the number of
instances in which it has actually been found in contaminated milk is
not large. One such has recently been reported by W. R. Stokes and
H. W. Stoner,^ in the case of an outbreak in a suburban town in Mary-
land in the autumn of 1912. The milk had probably been infected by
a woman employed in the dairy, who had suffered from typhoid fever
two years previously, and from whose stools the bacilli were recovered.

In last year's Annual a brief reference was made to the case of a

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TYPHOID FEVER

■winch-driver on board a steamer, a carrier ’’ who was believed to
have been the cause of twenty-seven cases of typhoid in about four
years. This man was admitted into the Marine Hospital in San
Francisco that his condition might be thoroughly investigated and
an attempt made to free him from the bacilli. A short account of
this research has been given by D. H. Currie and F. H. McKeon.-
Observations on the stools and urine were made weekly or bi-weekly
from March 28 to Oct. 14, 1912. Up to June 19, bacilli were found
in the stools, but not in the urine. After June 19, both the stools and
the urine were free. From April 27 to June 28, 1912, an autogenous
typhoid vaccine was injected subcutaneously. From a first dose of
25 million bacilli, the number per dose was increased gradually till
the final one contained 1,500 million. The first four injectioias pro-
duced only a local redness, ■without general reaction. The next four
(May 19 to June ii), produced a general as well as a local reaction,
though one of them was slight. The last two gave rise to rather severe
local, but no general, reaction. The man left the hospital on Oct. 14,
1912, and was ordered to present himself for examination once a
month for six months ; the period during which he had remained free
from bacilli was too short for it to be certain that he had bet^n
permanently freed.

Symptoms. — An account of two cases of “ typhoid spine has been
published by M. H. Rogers.® Both were examined by means of A'-rays.
Rogers thinks that the so-called ' typhoid spine ' is an osteomyelitis
of the vertebral bodies, which causes lesions similar to the typhoidal
bone abscesses of other bones, located in the cortex just beneath the
periosteum. Other observers, however, by means of the Ar-rays, have
found deposits of new bone or overgrowth.’'

In a very interesting paper, A. Robin, N. Fiessinger, and M. P. \\'eil*
put before us an account of the hcBmorrhagic conditions met with in
the acute infections, especially typhoid fever. They occur during the
early and late (convalescent) stages of typhoid, but the early and tlie
late hcemorrhagic syndromes are entirely different from one another in
their clinical course and pathology. The late syndrome is characterized
by purpura of the skin of the thorax and abdomen, epistaxis, buccal and
intestinal haemorrhage, and haematuria. The temperature oscillates ujj
to about 38° C. (ioo’4° F.), and the aspect rapidly becomes amemic.
The condition lasts for five or six days, and recovery is frequent. In
the early haemorrhagic syndrome a fatal result is neaxdy invariable. The
cause of the late haemorrhagic condition is attributed by the authors
to an alteration in the liquid constituents of the blood, which becomes
more fluid in consequence of a marked loss, during the course of the
attack of typhoid fever, of certain organic substances. This alteration
of the blood is shown by a lowering of its density and a sedimentation of
the red corpuscles. In some cases the haemorrhages are accompanied
by erythematous eruptions. The haemorrhagic syndrome is quite
distinct from the (so-called) infectious erythemas of convalescence,
which have been described by several writers, notably by Hutinel

TYPHOID FEVER

640

MEDICAL annual

cand Poisot. As for treatment, an effort slioiild be made to augment
the density of the blood and infcrease the organic content. Hence
they recommend Gelatinized Serum, and metals in the colloidal state,
especially electric Colloidal Silver, which should be injected into a
vein or a muscle.

An attack of almost every one — if not every one — of the acute
infectious diseases may run its course without any notable rise of
temperature. This may even occur in a disease with so long a duration
as typhoid fever. Norman Flower’s*'^ patient was a woman aged 60
years. The illness began with malaise and diarrhoea, and in a few
days the patient was compelled to take to her bed because of increasing
weakness. When first seen she was exhausted, had a dry, furred
tongue, and profuse diarrhoea. The temperature was subnormal.
Two days later she began to wander in mind, and sank into a semi-
comatose state, in which she remained for fourteen days, the diarrhoea
persisting ; there was moderate distention of the abdomen, but the
spleen was not enlarged, nor were any rose spots seen. " From the
onset of the attack until the fourth week of the disease, when complete
consciousness returned, the mouth and surface temperatures were
invariably subnormal, and the rectal temperature, taken twice daily,
never exceeded 99*4°. During the nine days following, the mouth
and rectal temperatures each reached their maximum of 99*6® and
100*4® respectively, after which they dropped again.” The diagnosis
of typhoid fever seems to have been made chiefly on the serum reactions,
which were positive in every dilution in the third, and again during
the fourth week (up to 1 in 2000). At the same time the reactions
with paratyphosHs A and B were slight, and with B. enter it idis
(Gaertner) negative.

Diagnosis. — According to Ch. Lesieur and J. Marchand," impaired
resonance over the base of the right lung behind is a valuable sign of
typhoid fever. From an examination of r 50 cases, of whicli 1 14 were
undoubted cases of ordinary typhoid, ij very mild and somewhat
doubtful cases, 18 other diseases than typhoid, aud t typhoid septic-
lemia with meningitis but without intestinal lesions, they conclude
that the dullness is present in about 80 per cent of the undoubted
cases, and in 50 per cent of the mild and doubtful It was present
in the septicaemic case. It was not found in the other diseases. The
dullness is not due to any pulmonary lesion, but to hypertrophy of
the liver consequent on its action in eliminating typhoid bacilli. It
can be found during the febrile stage, but disappears as convalescence
is established. It will reappear with a I'elapse. Indeed, in some cases
of relapse, the dullness persists even during the period of apyrexia
following the primary attack. This sign, therefore, has not only a
diagnostic but a prognostic value.

According to A. D. Radulesco and C. N. Atanassiu,’ pain on deep
palpation over the gall-bladder is a very constant sign of early typhoid
fever. The patient should lie on his back and be told to take a deep
breath. The physician, standing on the patient's right, palpates the

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641

TYPHOID FEVER

the right hypochondriac region with his left hand placed behind and his
right in front. Pressure should be made gently, but at the same time
firmly and continuously, deeply, and in an upward direction. The
patient will complain of pain more or less sharp ; should he be
unconscious theie will be strong muscular resistance, and at the same
time a facial expression indicative of pain.

G. C. Shattuck and C. H. Lawrence® give a comparative statement
of the frequency of occurrence of certain symptoms in two groups of
100 cases each ; those in the one proved to be t5q)hoid, and in the
other not. All the patients were over fourteen. In the 100 non-
typhoid patients in whom typhoid was suspected, bronchitis, broncho-
pneumonia and influenza represented 29 per cent, or nearly one-third
of the whole, undiagnosed fevers 15 per cent, and gastro-enteritis,
diarrhoea, and colitis 12 per cent. Absence of rose spots at the first
examination has little weight for diagnosis. The same is true of
splenic enlargement vrhen not demonstrable by palpation, and of the
Widal test when negative. A positive Widal is of the greatest
importance. Typical rose spots are vei-y important ; and a palpable
spleen is a valuable indication of typhoid, but is common in various
conditions simulating it. Atypical rose spots are useless for diagnosis.
Absence of leucocytosis in a febrile disease strongly suggests typhoid.
A white count below 5,000 is a valuable indication of typhoid fever,
and is unusual in conditions simulating it. A count about 9,000 is
presumptive evidence against typhoid. Bronchitis has no weight
per se one way or the other. The temperature in typhoid fever is
seldom below 100® F., whereas in other simulating conditions it is
commonly below 101°, In typhoid the pulse-rate is more apt to be
low in proportion to the temperature than in other diseases. (These
conclusions apply only to cases at the first time of being seen.)

Prognosis. — H. Harold Scott° contributes a paper on the value of
the JVidal reaction from the point of view of prognosis as w'ell as of
diagnosis. His conclusions are drawn from a study of 1,500 specimens
of blood. The standards he has employed are as follows : A serum of
dilution 1-30 should agglutinate an 18 -hours broth culture of the
organisms in question in fifteen minutes ; a dilution of 1-50 in
thirty minutes, and a i~ioo in an hour. He finds that “ when the
reaction is marked in high dilution and early in the disease, the course
of the disease is generally mild. In a case of average severity, the
reaction is usually quite distinct by about the seventh day of the
fever. ... In contrast to this, the outlook is more grave when the
reaction appears late.” He states that in some of these severe cases
a haemorrhage will produce a marked rise in the agglutinating power
of the blood within a few hours. He thinks that in some such cases
benefit would result if nature were to be forestalled by a small quantity
of blood being withdrawn by venesection, and the agglutinating power
of the serum thus raised.

He discusses at some length the significance of the agglutination by
the same serum of both B, typhosus and B. paraiyphosus A. The

TYPHOID FEVER

642

M3XDICAL ANNUAL

latter organism seems to be common in Jamaica, [It is not met Avitli
in the I'jnited Kingdom. — E. W. G.l. 'Hie general conclusion to be
drawn from his observations is, that if one of tlie organisms is agglu-
tinated but slightly compared with the other, the reaction is a “ group
reaction ” so far as that organism is concerned. Reactions in high
dilutions with both organisms point to a double infection.

Treatment. — S. J, Crowe, in 1908, showed that Urotropin, whether
administered by the mouth, intravenously, or subcutaneously, was a
very rapidly diffusible substance, and had a powerful germicidal effect
on the contents of the gall-bladder. He found that animals tolerated
large doses, and that in order to produce a fatal result in rabbits the
huge quantity of 10 grams per kilo of the animal’s weight was
necessary. He administered to the human subject doses of 4*5
grams (75 grains) a day. He treated 05 cases of various diseases in
this way, and in 7 of them observed luematuria. Three of the 7
patients died from the disease from which they were suffering
(meningitis), and an autop.sy showed in each case that the bleeding
has been from the bladder and not the kidneys. As in typhoid fever
the gall-bladder almost invariably contains the causative organisms,
it has been suggested by A. Chauffard and others that urotropin would
bo a valuable drug in that disease, not only as a curative remedy, but
also as a means of freeing the gall-bladder from the typhoid bacilli,
and thereby preventing the patient from being a carrier. H. Triboulet
and F. Levy^^ record three cases of typhoid in which from x to 6 grams
of urotropin (dissolved in sterile water) were administered daily, with
apparently beneficial results. No obvious haBinaturia was produced
in any; but in two, chemical examination revealed the presence of
pseudalbumin, and the microscope .showed red blood corpuscles and
epithelial cells from the bladder. J. Balkowski*^ treated 40 cases of
typhoid with urotropin ; 4 of them developed hamiaturia. (^ne was
fatal, from tlie severity of the disease, some days after tlic hannatiiria
had ceased. At the autopsy it wan found that there was considerable
extravasation of blood into the mucosa and submucosa of the fundus
of the bladder, hut notic into the kidneys, Tlic dosage employed by
J 3 alkowski was about -5 gram three or four times a day, by tlie mouth.
Three of the 40 cases wei'e fatal. He docs not think that urotropin, at
any rate in the doses he used, can be said to be a specific for typhoid,
but considered that on the whole the results he obtained were fa^'our-
able and encouraged a further trial of the remedy.

W. H. Walters^'* has collected from various sources and tabulated
1120 cases of typhoid fever treated by the specific Yaccines; 128 of
these were under his own care. There were 71 deaths, or 6*3 per cent, ,
certainly a low fatality. He speaks very favourably of the treatment,
and quotes several other observers to the same effect. According to
the table, the dosage has varied very widely in the practice of different
physicians. Some of the most convincing cases are those reported by
J. G. Callison.^*^ He gives six charts, which show that apparently the
fever was cut short by increasing doses of vaccine given at intervals

NEW TREATMENT 643 TYPHOID FEVER

of three or four days. He begins with 500 million, and increases by
100 million at a time. A few successful cases have also been reported
by B. M. Randolpb.^^

Diet. — Last year a full account was given of the method of feeding
by which loss of weight in this disease was to a very large extent
prevented. The plan advocated is based on Chittenden's investigations.
He showed, amongst other results, that the loss of protein could be
prevented or lessened by increasing the proportion of the fats and
sugars in the food. The reserve fat is lost first, and afterwards the
proteins. Further papers on this subject have been published by
Warren Coleman^® and M. H. Sicard.’-’ The former writer discusses
the weight- curves in typhoid fever. Loss of weight occurs in practically
all cases, but varies greatly in extent. The severer the infection and
the longer the duration of the disease, the greater the total loss. This
loss of weight has been attributed to three factors: (r) Partial
starvation ; (2) The febrile temperature ; and (3) The toxic destruc-
tion of protein.

1. It is generally admitted that the almost exclusively milk diet to
which it has been customary (until, at any rate, recently) to confine
the typhoid patient, has not afforded him sufficient nourishment ;
and that the loss of weight was due to partial starvation has been
shown by the success which has attended the practice of giving a
more nourishing diet, the loss of weight being much diminished and
even abolished thereby.

2. That the febrile temperature may account for part of the loss of
weight has been shown partly by experiment and partly by clinical
observation. The most marked effect is noticed when the temperature
has been continuously raised for a lengthy period.

3. It is a common belief that the toxins of the infecting micro-
organisms exert a directly destructive influence upon the proteins of
the body. Coleman does not discuss the truth of this belief, which
does not rest on so secure a basis as do those just mentioned. He
states that inasmuch as it has been found possible to bring a patient
suffering from typhoid fever into nitrogen and weight equilibrium by
the exhibition of a diet containing a large amount of carbohydrate
and a relatively small amount of protein, the correctness of the belief
does not concern us at this time. But in any discussion of weight-
curves in typhoid, it is important to refer to what is known as the
water-retention theory. There is some reason for thinking that in
cases where weight is not lost, the maintenance in weight is more
apparent than real, on account of the retention of water in the tissues.
Opinions are divided, and the evidence, one way or the other, is very
inconclusive. As for the influence of a diet rich in carbohydrate on
the retention of water, it is well known that a poorly-balanced diet
may cause variations in the excretion of water ; but a well-proportioned
diet does not affect the water-balance.

Referring to certain observations of his own, Coleman writes that
while the proportion of the foodstuflEs in the diet which he has employed

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644

MEDICAL ANNUAL

lias varied necessarily with different patients, and in some instances
has been subject to sudden experimental changes, there has been no
constant relation between variations in weight and the quantity of urine.
Though water may have been retained by some patients, and have
caused an increase in weight, there has been no clinical reason to
think that such was the case. There has been no visible oedema,
and patients have not lost weight suddenly, after diuresis, when
the amount of carbohydrate in the diet was diminished during
convalescence.

The writer gives charts and notes of cases to show that it is possible
to maintain patients suffering from typhoid fever in weight equilibrium
throughout the entire course of the disease by giving them sufficient
food. Sicard’s contribution gives further experience with high-calory
diets. He has come to the conclusion that patients do much better
on such diets than on milk alone. The most evident features of the
high-calory feeding, he states, are the sustenance of weight and
nutrition, the amelioration of hunger, and the lessened tedium of
convalescence.

Not a few persons have a great dislike to milk, even in small
quantities ; consequently, when such an individual falls ill with typhoid
fever, there is considerable difficulty in getting him to take sufficient
nourishment. W. N. Johnson and C. C. Watt,^® and also I. Bram,^^^
have treated a number of typhoid cases without any milk whatsoever.
Gelatin was one of the principal items in the diet. Johnson and Watt
write thus of its use in a considerable number of cases : " Great reliance
was placed on gelatin, which was given almost ad Uhitmn. According
to Kemp, the ingestion of 7*5 per cent of the total heat requirement
of the organism in the form of gelatin spares 23 per cent of the body*s
protein. A total of 2,800 calories is required by a man of 154 pounds
weight (Chittenden) ; 210 calories in gelatin, i.e., about 50 grams
of gelatin, or about i'5 oz,, are necessary. This amount in one quart
of water gives a 5 per cent solution, and can be flavoured with lemon,
vanilla, etc."

The following is a specimen of a milk-free diet employed for typhoid
cases by Johnson and Watt : —

6 a.m. : Barley gruel, sugar of milk, i dr., and yolk of 1 egg ;
total, 10 oz.

8 a.ni. : Gelatin, 6 oz.

9 a.m. : Lamb broth, 10 oz.

11 a.m.: Gelatin, 6 oz.

12 noon; Rice gruel, sugar of milk, i dr., and yolk of i egg;

total, 10 oz.

2 p.m, : Gelatin, 6 oz.

3 p.m. : Same as at 6 a.m.

5 p.m. : Gelatin, 6 oz.

' 6 p.m. : Same as at noon.

8 p.m. : Gelatin, 6 oz.

9 p.m. : Pea soap, 10 oz.

With very few exceptions, no feeds were given at night. Besides the
food mentioned above, the patients were allowed to have as much

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645

TYPHOID FEVER

water as they liked. After each feeding, ten drops of Dilute Hydro-
chloric Acid were given in the water. Bram advocates Olive Oil as
well as gelatin. It is certainly very useful in preventing constipation, -
especially during the early convalescent stage.

Prophylaxis. — The literature relating to Antityphoid Inoculation
continues to accumulate. Much of it comes from the United States,
because typhoid fever is still very prevalent there and opportunities
of studying it on a large scale from every point of view are afforded
more extensively than in Europe. Some of the most instructive
papers are those by F. F. Russell. 2® In one he shows that in the U.S.A.
army the incidence of typhoid has been remarkably reduced since the
introduction of inoculation. Voluntary vaccination was begun in 1909,
but only four soldiers availed themselves of it. During 1910, however,
upwards of 16,000 were vaccinated. During 1911 this protective
measure was gradually made compulsory, so that by the end of the
year it was extended to all persons in the military service under 45
years of age. Before 1910 the annual incidence of typhoid in the
whole army, at home and abroad, varied from 6*9 per thousand
in 1902 to 3*2 in 1908. It was as high as 5*7 in 1906. In 1910
it was 2-4, in 1911, 0*85, and in 1912, 0*31. In another paper,
Russell gives an interesting comparison between the results obtained
at San Antonio and along the Mexican frontier during the spring
and summer of 19 ii, and in the records of the Spanish War. ‘'A
division of troops, about 20,000 men, was mobilized in Texas and
along our southern boundary as far west as San Diego, Cal., in
March, 1911 ; they remained in camp and on march for a period
of over four months ; then the majority returned to permanent
army posts.*' All these men were vaccinated against typhoid. The
immunization was carried out after the troops arrived at their destina-
tion, and while they were under canvas, without interfering with their
work. As a result we have to record only two cases of typhoid, one
in Texas and one in California, both ending in recovery, in the entire
number of troops in the field. In 1898, during the Spanish War, there
were assembled at Jacksonville 10,759 troops, among whom there were
certainly 1,729 cases of typhoid, and including those probably typhoid,
2,693 cases, with 248 deaths. This camp lasted approximately as
long as that at San Antonio ; the number of men was less by about
2,000 ; the troops were situated in about the same latitude, and both
were furnished with artesian well water ; yet in 1898 there were over
2,000 cases and 248 deaths, and in 1911 there was one mild case. We
know that this immunity was not due to lack of exposure, since the
fever prevailed to a considerable extent in and around San Antonio."
The writer admits that the hygienic and sanitary condition of the
recent camps was better than that of those of 1898, but this does not
account for the lessened incidence of typhoid.

In both these papers, as well as in a third^^ on antityphoid vaccina-
tion in children, Russell advocates the extension of the practice to the
civil population. In this view he is supported by Weston, Hachtel

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MEDICAL ANNUAL

and Stoner, and Spooner, who publish accounts of the protective
results of protective inoculation in vaidoiis hospitals and institutions.
All these writers agree in stating that antityphoid inoculation, if
properly carried out, does not produce any ill elfects.

The efficacy of vaccination during the course of an epidemic is
discussed by C. J. Hiint‘*^« in the case of the epidemic which occurred
at Troy, Bradford County, Pennsylvania, in October, 1912. In spite
of the fact that 4*8 per cent of the vaccinated and 14*2 per cent of the
unvaccinated developed the disease, the writer, from epidemiological
considerations, writes that the pertinent conclusions from the studies
made in this one epidemic indicate the little value antityphoid vaccine
had in limiting the number of cases and in modifying the process in
the individual case. . . . The use of vaccine should be limited to those
not already infected, that is, to prevent secondary cases.”

CastellanP’ has published an account of further experiments in
vaccination with living attenuated vaccines. He finds that the use
of such vaccine prepared according to his method is harmless. In
preparing it, the strain should be non- virulent but rich in antigen, as
found out by animal experiments. Such vaccine in the lower animals,
and probably in man too, gives rise to a higher degree of immunization
than that obtainable with dead vaccines. It must be stated, however,
that in man the immunization obtained by two inoculations of this
vaccine, or any of the dead vaccines, is never complete ; it is only
partial. Various mixed vaccines can be prepared, either dead or live
attenuated vaccines. Castellani is of the opinion that in countries
where paratyphoid A and B are endemic besides typhoid fever, a
mixed vaccine of the three organisms should be used.

Leary^s records two cases of Removal of the Gall-bladder in typhoid
carriers. In one the patient had had gall-stones removed previously,
and a chronic and troublesome biliary fistula had restated. There was
no history of typhoid fever in this patient, but he was found to be a
carrier, with bacilli in the contents of the gall-bladder, as well as in the
fajccs. The other case was one in which the patient had become a
chronic caiTier as a result of an attack of typhoid fever. In both
cases the fseces were still free from typhoid bacilli some weeks after the
operation.

Those who have not been able to obtain the original Cierman accounts
of the antityphoid campaign carried on in certain parts of Germany
during recent years, will hnd an excellent summary, with a description
of the organization, in a paper by W. F, Ford,^® who paid a visit to
Saarbriicken for the purpose of studying the methods employed.

References.— '/ own Amer, Med, Assoc, 1913, if 1024; Hbid. i, 183;
^Bost. Med. and Surg. Jour. 1913, i, 348; ^Rev, de Med. 1912, if 673;

Med. Jour. 1913, i, 270; ^Fresse Med. 1913, 625; "^Ibid. 1912, 1004;
^Bost. Med. and Surg. Jour. 1913, if 228; ^Fract. 1913, ii, 589; Johns
Hop. Hasp. Bull., 1908, log \ J^Pr esse MM. 1913, 145; ^^Rev. de M 6 d
1913, ii, 663 ; ^'^Med. Rec. 1913, ii, 518 ; ^^Amer. Jour. Med. Sci. 1912, ii, 350;

Med. Jour, 1913^ h, 453 ; ^^Amer. Jour. Med. Sci. 1912, ii, 159;

Rec. 1913, i, 523; ^^N.Y. Med. Jour. 1913, i, 228; 1913, ii.

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647

ULCERS

230; “^Jour. Amer. Med. Assoc. 1913. ii, 6(>6; 1362 ; ^^Ihid. i, 344 ;

^Hhid. 1912, ii. 1536,* 'Mbid. 1364; -^Ibid.\ 1359 ; -^Amev. Jour. Med. Set,
1913, i, S26; -"^Lancet, 1913, i, 595 ; -^Jour. Amev. Med. Assoc. 1913, L 1293 J
Johns Hop. Hosp. Bull. 1912, 2G9.

TYPHUS FEYER. E. W. Goodall, M.D.

In a paper in which he disensses the problem of typhus in the United
States, J. F. Anderson^ brings forward evidence which strongly suggests
that the disease is much more prevalent in the large American cities
than is usually supposed. The discussion arose out of a study of
certain cases of so-called “ BrilFs disease/* which is now acknowledged
by most authorities to be typhus. At present, however, typhus in the
United States has a low case-mortality and shows but little tendency
to spread. Often, too, the symptoms are not particularly characteristic.
Anderson points out that guinea-pigs are quite susceptible to typhus
when inoculated intraperitoneally with blood from victims of the
disease during the active febrile period, though the only indication of
infection in the animal is the temperature curve, which, in its rise,
duration, and fall, is quite typical and readily recognized. He suggests,
as a procedure of value in arriving at a correct diagnosis, the inoculation
of guinea-pigs intraperitoneally with about 3 c.c. of blood from cases
of continued fever giving a negative Widal and blood-culture ; especi-
ally in cases in which there has been a sudden onset, an atypical
eruption, intense headache, apathy, and prostration. For the identity
of “ Brill’s disease ” with typhus, a paper by Roger Lee^ may also
be consulted.

References.' — ^ Jour Amer, Med. Assoc. 1913, i> 1S45 ; ^ Bosf. Med. and
Surg. Jour. 1913, i, 122.

ULCERS. E. Graham Little, M.D., F.R.C.P.

Heidingsfeld and May^ conducted experiments on the toxicity of
Basic Fuchsin (Grubler), stated by the latter to consist of a mixture
of rosanilin and pararosanilin hydrochloride. Satisfied of its compara-
tive non-toxicity, they treated twenty cases of chronic ulcer with an
ointment consisting of : —

B Fuchsin (Grubler’s “ fuchsin | Eucalyptus Oil 10 parts
fur baktericn *’) 5 parts ) Anhyd. Wool Fat 100 parts

The ointment was applied daily on lint.

Within six weeks ten of the cases had made excellent progress. When
dermatitis results from this ointment, a weaker formula may be substi-
tuted, e.g. : —

B Fuchsin i part 1 Anhyd. Wool Fat 100 parts

Petrolatum 5 parts | .

The substitution of commercial fuchsin for the Grubler preparation
was not attended with success. Merck’s fiichsine medicinal seems to
possess the same properties.

Greene^ reports the cure within three weeks of a varicose ulcer, two
by three inches in extent, by the application thrice daily of a mass of

UMBILICAL INFECTIONS

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MEDICAL ANNUAL

well-ripened full Cream Cheese, mixed with cream and water, spread on
gauze. The cheese would disappear in five or six hours. The patient
could take no rest, and was engaged throiighoLit the treatment in
active farm and dairy work.

Reference. — ^Jouv, Amev. Med. Assoc. I9i3> L 1G80; "^Med. Rec, 1913, ii,
481.

UMBILICAL INFECTIONS IN THE NEWBORN.

Fyedenck Langmead, M.D., F.R.C.P.

It is generally recognized that the umbilicus is the portal for a
majority of the infections in the first few days or weeks of life. Among
the results of umbilical infection at this age, lesions of the lung are
some of the most important ; indeed, a rapidly fatal septicasmia may
manifest itself clinically by signs of pulmonary disease alone. M. E.
Bonnaire and M. G. Durante^ have recently described in detail the
pulmonary complications which umbilical infection may produce.
They divide the lesions into three classes : purplish ill-defined areas of
congestion arising as the result of toxaemia alone, and therefore free
from micro-organisms ; miliary infarcts with or without surrounding
zones of inflammatory reaction, sometimes coalescing to form nodules
of hepatization, which nearly resemble broncho-pneumonic areas, but
differ from them in the absence of bronchitis and the presence of
organisms in the vessels ; and, lastly, cicatrices found in the lungs of
babies, who survive the lung affection, but succumb afterwards to
some other disease. The form of the lesions varies according to the
mode of invasion of the infection. Thus there may be a local cellulitis
with general toxaemia, a gradual infection of the blood-stream, or
embolism with pyaemia.

Diagnosis of these conditions is difficult, as the signs are very in-
definite, the only distinctive one being the presence of small areas
of dullness, to elicit which very light percussion is necessary. In
some cases the local condition does not suggest to the observer that the
navel is the source of infection.

Prognosis depends upon the nature of the infecting micro-organism.
With saprophytes only the outlook is favourable ; streptococcal infec-
tion is almost always followed by a fatal septicsemia, whilst staphylo-
coccal infections occupy an intermediate position in point of gravity,
chiefly because they usually remain localized to the navel. In prema-
ture infants these infections are very fatal. Many of the infants who
recover remain in a state of feebleness, or are permanently damaged
to a greater or less degree.

j ; These writers give statistics which show the importance of the pul-
monary complications of umbilical infection. In 2603 infants umbili-
cal infection occurred 832 times. Post-mortem observations revealed
lesions in the lungs in 20 per cent of the cases examined. During life,
however, only 5 per cent gave signs of lung disease, an indication of the
difficulty of detecting this affection clinically.

Reference. — ^Fresse Mid. 1913, 553.

PLATE LXIIL

la . — Tlie buccal capsule oj Hecator americanasAh.'^Tlie same ma^nifiec/ ,

2 a, — Copulaiorij bursa of Lie cator amerfcanu^. Z b. -branches of c/orsal raij magnified.

Sa. — The buccal capsule oJ Ankijlosioma duodenale. 3b.^The same

inaynijied .

4a — Copulatorij bursa of A nkylostoma ducdeaale. 4b.-The dorsal ra^ ma^ni^ied.

Su — Buccal capsule ^ A ^chylostom a ceylanicum. Sh.- The same magnijied.
6a. — C&pulcdortf bursa of Agchylostoma ceylanictrm. 6h.~Porsal ray mnynified.

P>o/. L. Ro^e)S

NEW TREATMENT

UNCINARIASIS

UNCINARIASIS. Leonard Rogers, M,D,, ^F,R,C,P.

E. R. Stitt^ describes and illustrates a quick way of differentiating
the species of hookworm met with in man. In order to get the right
views of the worms, fresh ones are placed in salt solution under a cover-
glass and rolled on their long axis by manipulating the cover-glass with
a toothpick, and examined with a f-in. objective. By getting a direct
view into the buccal cavity, the four hook-like ventral teeth of the Anky-
lostoma duodenale contrast with the smaller opening, semilunar lips,
and prominent dorsal median tooth of the Necator americanus. Next
the copulatory bursa of the male is examined, and the deep cleft and
bipartite tips of the two branches of the dorsal ray of the necator
distinguish it from the shallow cleft and tridigitate tips of the ankylo-
stomum. In the female the vulva is at or near the posterior third in
the ankylostomum, but near the equator, but in the anterior half, in the
American species. For preserving specimens for subsequent examina-
tion, he recommends Braun’s and Luhe’s solution, consisting of lactic
acid, glycerin two parts, and lactic acid, crystallized phenol, and water,
each one part, after fixing in 2 per cent formaldehyde for two hours.
For pennanently mounting, ring the cover-glass with gold size.
{Plate LXIII,)

Clayton Lane^ records the occurrence of Agchylo stoma ceylaniciim in
a man in India, this worm having previously first been described by
Looss in material from a civet cat from Colombo. Lane has now
found it commonly in dogs and cats in Bengal, as Looss suggested
probable, and during the examination of prisoners in the Berhampore
gaol the new form was found in three of them. It is smaller than A .
duodenale ; the head end is largely transparent when fresh. Of the two
pairs of ventral marginal teeth, one pair is deep and cephalad, and the
other are superficial and caudal. The bursa of the male has marked
clefts dividing the dorsal from the lateral lobes ; the dorsal ray bifur-
cates, and each branch again bifurcates, while the edge of the dorsal
lobe of the bursa has a single convex curve on each side of the middle
line, the tw''o curves producing an outline like that of a weak figure 3.
The lateral lobe is rather long and rounded. If this worm proves
to be common in man, the fact that domestic animals harbour the
parasite will introduce an important factor in the prophylaxis against
infection.

B. K. Ashford® gives a graphic description of the important economi-
cal aspects of the widespread occurrence of severe degrees of ansemia
caused by hookworm disease in Porto Rico, where he was the first to
draw attention to the true nature of the scourge. He* has been closely
identified with a gigantic and wonderfully successful campaign since
waged against the evil, which was sapping the strength of the labourers
and reducing their working capacity to a fraction of its normal level.
Since 1904, 300,000 persons have been successfully treated by the
Commission alone, and very large additional numbers through other
agencies. Formerly, the deaths from ansemia alone amounted to 15
per cent of the total, while the average haemoglobin was only between

UNCINARIASIS

650

MEDICAL ANNUAL

50 and 60 per cent. The mortality from anaemia has now fallen to
only one-eighth of what it used to be, and only remains of any
importance in far-away mountainous areas. These good results
are testified to by the replies of 224 planters living in all parts of
the island.

R. Saundby'^ describes the occurrence of ankylostoma in very small
numbers, not more than three ever having been found in a stool after
treatment with thymol, etc. He attributed serious nervous symptoms
with fits of unconsciousness to the infection ; but in view of the fact
that 60 to 80 per cent of healthy people in India harbour such small
numbers of ankylostoma it is extremely doubtful if they were of etio-
logical importance in Saundby’s patient.

E. J, Wyler ^ deals with this disease in the Udi district ot Southeim
Nigeria. No less than 199 out of 200 people examined hax'boured the
hookworm, both varieties being met with. The ova were easil}?- found,
indicating a heavy infection, while other worms were present in addition
in 56 per cent of the cases. Thymol in quantities of 90 gr. proved
harmless and effective. Anaemia of a moderate degree was found in
79 per cent of the subjects.

References. — ^Jonv. Amer, Med. Assoc. 1912, i ; Med. Gaz. i9I3j

217 : ^Amcr. Jour. Med. Sci. 1913, i, 358 ; ^Lancet^ I9I3j i» 1223; ^Jouv. Trap.
Med. and Hyg. 1913, 193.

URETERAL OBSTRUCTION. /. W, Thomson Walker, M.B., F.R.C.S.

H. D. Furniss^ finds that strichtre of the ureter is more frequent than
is generally supposed. The diagnosis, especially on the right side, is
frequently mivStaken. The most common causes are inflammatory,
and the infection may be descending or ascending. The most certain
method of diagnosis is pyelography.

Walter S. Reynolds- reports a case of ureteral calculus treated by Oil
Injections into the ureter. A number of these injections were inade^
and the stone was eventually passed. A case of calculi in the pelvic
portion of the ureter operated on by the transperitoneal route is I'ccorded
by George Wherry.'* Tliis plan wUvS chosen as tlie calculi were situated
so deeply in the pelvis that a large wound would have been required
for an extraperitoncal operation, with subsequent drainage, and there
would have been difficulty in suturing the wound in the ureter.

F. Kidd"* describes a small muscle-splitting incision for the exposure
of the pelvic portion of the ureter. An incision 3 in. long is made
through the skin i| in. above Poupart’s ligament, and extending
from the edge of the rectus muscle 2 in. outwards and i in. inwards.
The centre of the incision lies vertically above the internal abdominal
ring. The external oblique aponeurosis is split in the direction of its
fibres I in. inwards in front of the rectus muscle and 2 in. outwards
from it. The internal oblique and transversalis muscles are split in
the direction of their fibres for 2 in. outwards from the outer edge of
the rectus muscle and i in. inwards through its anterior sheath. The
rectus muscle is separated from its posterior sheath and retracted

NEW TREATMENT

URETHRAL DISEASES

651

inwards. The transversalis fascia is torn through external to and
above the deep epigastric vessels, and the peritoneum pushed upwards.
The rest of the opei*ation follows conventional lines.

References. — ^Jouv, Amer. Med. Assoc. 1912, ii, 2051 ; ^Med. Rec. 19^2,
ii, 1078 ; Med. Jour. 1913, i, 1043 ; ^Lancet, 1913, t 157^-

URETHRAL DISEASES. /. W. Thomson Walker, M.B., F.R.C.S.

J. L. Herman^ records a case of so-called double tirethra occurring
in a Jamaican negro of twenty -four years. The accessory canal arose
from the point of the glans penis just above the normal meatus, the
two being separated by a very thin plate of tissue. It extended back-
wards to the mid-point of the root of the penis, traversing the body
of the organ diagonally and becoming more superficial posterioidy.
A gonorrhoeal infection of the urethra and accessory canal persisted
in the latter, and resisted treatment until the posterior end of the
canal was opened at the base of the penis under local anaesthesia,
and the canal thoroughly irrigated.

An operation for penile hypospadias in three stages is described
by Arthur Edmunds.’^ Stage I. ; A transverse button-hole incision
is made through the whole thickness of the prepuce, and the edges
stitched round like a button-hole. The object is to divide the dorsal
vessels of the prepuce and lead to the foi'mation of a number of
smaller lateral vessels. Stage II. : Three months later an incision is
made through the prepuce from the middle of the button-hole to
the free border, so as to form two flaps. An incision is now made
along each side of the urethral groove, and these are joined in front
by an incision in the glans around the point where the meatus would
normally be situated. The urethral groove is dissected up completely
from before backwards, and the penis can now be straightened. An
incision is made on each side from the anterior end of the raw area
thus produced, and carried around the corona glandis until the middle
of the preputial flap is reached, when the direction of the incision
is changed to the long axis of the flap to its end. The lax tissues arc
now opened out, the skin made to cover the whole of the raw area,
and stitches are introduced. Stage 111. : Three months later a soft
rubber catheter is passed along the under surface of the penis and
into the urethra which opens at its base, and is stitched in place. An
incision is made on each side of this, and flaps are raised and sutured
over the catheter. The skin is raised on either side and drawn
together over this. Fistulae are most likely to form at the base of
the glans or just in front of the scrotum, and ai’e closed by turning
a flap of skin over from the side and coveiing this by a second flap.
The operation can be performed at any time after the age of three,
but it is easier when the child is older.

Urethral Defects. — ^According to Muller,’* the method of Thiersch
Grafting has not yet been seriously employed. The urethra possesses
a remarkable power of regeneration, and in small defects repair takes
place by natural means. In larger defects the most simple method

URETHRAL DISEASES

652

MEDICAL ANNUAL

is to take advantage of the elasticity of the urethra and to mobilize
the cut ends. When the urine is aseptic, careful suturing holds.
In this way defects as great as 6 cm. (Goldmann) and 9 cm. (Sick)
have been repaired. Sometimes, owing to extensive scarring, there
is great difficulty in mobilizing the urethra. In such cases, hollow
tubes, such as portions of a vein, have been transplanted. There is,
however, no certainty that the lumen will be maintained. The author
relates five cases in which Thiersch grafts were successfully used.
The grafts are applied at once after resection of the stricture or
operation for hypospadias, and when the whole of the wound right
up to the outer skin is covered with a layer of epithelium, a plastic
operation is carried out by turning flaps over a catheter.

FisiulcB . — Urinary fistulse after perineal prostatectomy are, according
to Lothrop,^ not uncommon. In some cases careful operator’s are
able to remove the gland without material injury to the urethra,
but, as a rule, it is considerably torn. With a view to preventing
such fistulse, the author recommends that care should be taken to
avoid injury, a catheter introduced along the whole urethra, and a
light gauze packing left in the wound. In many cases the wound
may be nearly closed with large silkworm-gut sutures. If there is
no contraindication, the catheter should remain in the urethra for
at least one week. For fistula following external uiethrotomy for
stricture, the author recommends dissection of the track, suturing
of the communication with the urethra, and tying a catheter in the
urethra.

Stricitire, — J. R. Eastman® describes a method of Continuous
Dilatation of extensive urethral stricture. When a catheter is placed
in the urethra there are two situations at which it becomes bent :
at the membranous urethra, and at the penoscrotal junction. Severe
inflammation and abscess formation have been known to follow. To
avoid these disadvantages, the author introduces one catheter through
the prostatic urethra into the bladder through a perineal incision,
and places a second in the anterior urethra reaching down to the first.
This serves to produce continuous dilatation of the stricture. Largo
soft rubber catheters are used.

A method by which the Wheelhouse operation is rendered easier in
cases of impassable stricture of the urethra is described by A. B.
Cecil.® A solution of methylene blue, when injected into the urethra,
will permeate and stain the canal in such a manner that it can be
followed throughout its entire course. The solution used is i gram
of methylene blue to 200 c.c. of distilled water. The injection is
made .with moderate pressure at first, and then with more force.' The
stain is allowed to remain in for five minutes, and the canal is then
washed with sterile water. A sound is passed down to the stricture,
the end cut down upon, and the urethra retracted. The further
course of the canal is indicated by the blue stain ; a grooved director
is then passed along it, and the incision carried backwards. The
method may also be used for dissecting out perineal fistulas.

NEW TREATMENT

^53

URETHRAL DISEASES

In an article on impermeable stricture of the bulbomembranous
urethra, John B. Deaver’ considers five methods of operative treat-
ment. Perineal section he considers “ blind and time-consuming.'"
Incision of the urethra anterior to the stricture, the passage of a probe
or filiform bougie through the stricture, and incision of the stricture
on this, is the most commonly used method and is usually easy. The
disadvantage is that, when it fails, a perineal dissection must be com-
menced. Cock’s operation (incising the urethra at the apex of the
prostate) left the stricture untouched. The method advised by Young
is also advocated by Deaver. The apex of the prostate is exposed
as if to commence perineal prostatectomy. The urethra is incised
through the tissue at the apex of the prostate, a sound passed forward
to the posterior face of the stricture, and the stricture cut. He does
not favour the method of suprapubic cystotomy, retrograde catheteri-
zation, urethrotomy behind the stricture, and incision of the stricture.

C. G. Cumston^ states that in regard to utilit}^ of Resection opinion
is unanimous, but the same cannot be said in regard to reconstruction
of the urethra. Once the resection is done, the choice is offered
between secondary union, immediate end-to-end suture, simple
urethrostomy, and urethrorrhaphy with deviation of the urine.
Secondary union without sutures, with a permanent catheter in the
bladder, has given unsatisfactory results. The immediate effects of
end-to-end sutuie may be good, but the ultimate results are not
always favourable, for secondary infiltration may occur round a
suture and lead to the development of scar tissue. Both these
methods necessitate a permanent catheter during convalescence, and
this prevents primary union. Urethrostomy is “a, temporary gun-
barrel suturing of the two ends of the urethra to the perineum after
rupture or operation wound of the canal.” Another indication for
this procedure is wide separation of the cut ends after extensive
resection of the canal. Urethrostomy necessitates interference two
or three months later, in order to close the perineal meatus and recon-
struct the canal.

The operation performed by this author is Urethrorrhaphy with
deviation of the urine. An incision is made in the middle line of the
perineum over the stricture. All the scar tissue is removed with
scissors, and a clean-cut anterior and posterior end to the canal
obtained. As much as 6 cm. of the canal can be removed without
danger. The posterior part of the urethra is dissected out from
I to 2 cm. and the anterior is freed from 3 to 5 cm. The ends must come
in contact without tension. The anterior end of the urethra is brought
down and fixed by catgut sutures to the periurethral tissues on
each side. When these are tied, the anterior and posterior ends can
be approximated without tension. Two fine catgut sutures are placed
in the anterior portion of the urethra without including the mucosa,
and similarly carried tlirough the posterior end. A large sound is
passed into the bladder and the two sutures are tied. The remaining
sutures are now inserted with the sound in place, and all the knots

URETHRAL DISEASES (354 MEDICAL ANNUAL

arc tied outside the canal. An opening is now made in tlie bulbous
methra at least x’5 cm. behind the line of suture, and a catheter
passed tlirough this into the bladder after witlidrawing the sound.
The catheter is fixed with silkworm-gut sutures passed through the
edges of the cutaneous incision. The soft structures are approximated,
lea\tng space for drainage alongside the catheter, which is removed
on the tenth day, the fistula closing in a week.

References. — W. Y. Med, Jouy, 1913, i, 919 ; '^Lancet, 1913, h 447;
med. Woch. 1912, 2307 ; '^Bost. Med, and Surg. Jour. 1913. i» 1S8 ; ^Jour,
Amer. Med. Assoc. 1912, ii, 2064; ^Ibid. 1913, i, 160G ; Ubid. 262 ; Mnn.
Surg. 1913. h 53 ^*

URINARY INCONTINENCE IN WOMEN. also Uterus, Displace-
ments, OF.) Victor Bonney, M,S,, M.D., B.Sc,, F.R.C.S.

Bryden Glendining, M.S., F.R.C.S.

Howard Kelly^ describes an operation which he has found invariably
successful in cases of incontinence of urine in women in which, from
previous injury, generally the result of labour with application of
forceps, there has been bruising of the muscles in the region of the neck
of the bladder or of the sphincter urethrae, with consequent inefficiency
in control. The symptoms may be those of a true incontinence, or of
an intermittent character, such as is evidenced after a certain degree
of fullness, or a jet of urine upon some unusual increase in intra-
abdominal tension, e.g., coughing or stepping on to a tramcar. Many
of these patients have previously seen a specialist, who performed a
colpoperineorrhaphy, or perhaps tried bringing the tissues together
over the urethra from below in the vagina, or kinking the urethra upon
itself. Kelly^s method is to cut down upon a mushroom catheter
which engages in the neck of the bladder, so as to define its muscles ;
then with mattress sutures he laces the relaxed or torn muscles
together beneath the catheter.

ChenhalR repents a case of cui*e of frequency of micturition in an
elderly woman by ventrofixation of the uterus. The uterus was found
acutely antencxed and resting on the bladder.

Referi-inces. — •^Therap. Gas. X912, <>85; Kiu.strcd. Med. Gas, 1913, 123.

URINARY INFECTIONS. {See also Pyelitis). Francis D. Boyd, M.D.

Jordan,^ in a report on urinary antiseptics, finds that the acidity of
the urine is readily increased to an extent of more than double the
normal by the administration of Acid Sodium Phosphate, and to a
considerably less extent by Benzoates; with large doses of Citrate
it is usually rendered alkaline. Urinary putrefaction and the gi*owth
of staphylococcus is aided by alkalinity and delayed by acidity in
proportion to the amount thereof. The reverse is the case with B. coli,
but only to a small extent, for its growth is luxuriant in both acid and
alkaline urines. Hexamethylenetetramine (urotropin) is not itself
antiseptic, but only acts after the liberation of formaldehyde in the
urine. This only takes place in acid urine, for this substance is inert
in an alkaline medium. The degree of antiseptic power is in proportion

NEW TREATMENT

655

URINARY INFECTIONS

to the acidity, and it is the most ef&cient urinary antiseptic when the
acidity of the urine is normal or supernormal. There appears no
evidence that helmitol acts differently from hexamethylenetetramine
when excreted in the urine. Sandalwood Oil is a poor general anti-
septic, but appears to have a specific action on the staphylococcus
which may apply to cocci generally. It is of some use in alkaline
urine. Boric Acid is an efficient antiseptic ; its action is unaffected
by alkalinity, so it is the most efficient substance we possess when the
urine is alkaline. Uva Ursi is a good antiseptic ; its action is certainly
not due chiefly to the arbutin it contains.

The legitimate practical deductions appear to be that Urotropin,
together with acid sodium phosphate, may be used as a prophylactic
before any operation or procedure where the urine may become
infected, and is of the utmost value, since, if the urine is highly acid
and sufficient urotropin given in small doses to keep it constantly
charged with formaldehyde, it becomes a powerful antiseptic fluid in
which organisms cannot live. Urotropin should only be used when
the urine is or can be made acid ; otherwise it is inert. It should never
be given with potassium citrate in B. coH infection. If it be desired
to try the effect of making the urine alkaline in these conditions, boric
acid or the uva ursi infusion should be employed as antiseptics, along
with citrates. Where the urine is undergoing ammoniacal fermentation
in the bladder, bladder washes or other operative procedure will always
be a most important part of the treatment. The best medicinal
substances to use are Boric Acid in large doses, Uva Ursi, and possibly
Sandalwood Oil. Sandalwood oil is always worth trying in cystitis
due to the staphylococcus alone. When acid sodium phosphate is
prescribed, it is as well to write the chemical formula NaH.^PO^ on
the prescription, and to ascertain that the right phosphate is being
dispensed. It is worth while, in giving these substances, to estimate
the acidity of the urine occasionall}^ to make sure that there is an
increase. Unless the acidity is kept high, urotropin will not act
efficiently, and a high acidity is of much more value than large doses
of urotropin.

In a discussion on urinary antiseptics, Thomson Walker-^ strongly
urged that the urine should be examined for the presence of form-
aldehyde. Without a systematic examination of the urine, the physician
is in the dark as to whether formaldehyde is being liberated or not.
The tests advised are as follows : (1) Phloroghwin test. — The following
solutions are used : {a) Aqueous solution of phloroglucin (i per cent) ;
(b) Solution of caustic soda (30 per cent). A few drops of phloroglucin
solution are added to the urine in a test tube, and then 5 drops of the
caustic soda solution. A bright cheiTy-red colour appears if form-
aldehyde is present, but no colour if there is only urotropin in the urine.
This test will show the presence of formaldehyde in a dilution of
1-50,000 in the urine. (2) Bnrnam's Modification of Rimini's Test . —
The following three solutions are used {a) Phenyl-hydrazine hydro-
chloride, 0*5 per ^cent ; (6) Sodium nitro-prusside, 5 per cent ;

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MEDICAI. ANNUAL

(c) Sodium hj^drate, saturated solution. Three drops of each of the first
two solutions are added to the urine, and a few drops of the soclium
Iwdrate solution poured along the side of the test-tube. If form-
aldehyde is present, a deep greenish-black colour passes down tlirough
the urine and clouds it. This rapidly changes to green, and fades
through bright garecn to orange and pale yellow. The urine and the
sodium hydrate solution should be wanned to slightly above body
temperature. This test will detect formaldehyde in urine in a dilution
of 1-150,000, but does not show the reaction wdth urotropin. Accord-
ing to Burnam, there is an intense dark blue colour, changing to green
in solutions of 1-20,000 or stronger, and in solutions of less strength
the first colour is an .intense green. If these tests for formaldehyde
are negative, a fresh sample of urine should be boiled, after the addition
of a few drops of sulphuric acid. The test is then applied, and if
the formaldehyde reaction is now present, the urine has contained
urotropin.

References. — ^Brit. Med, Jour, 1913, ii, 648 ; 654.

URINE TESTS. {See also Proteinuria ; Renal Efficiency ; Urin-
ary Infections.) 0 . C. Gninev, M.D,

Glucose, — Colei discusses the fact that small amounts of glucose in
the urine occur much more frequently in health than is usually believed,
and shows that the limits of tolerance to a carbohydrate diet in various
pathological conditions might be usefully studied. He finds that the
fallacies existing with the Fehling test could be overcome by the use
of blood-charcoal to take up the urates and creatinin, while the addition
of lo per cent acetic acid or 15 per cent acetone would prevent the
absorption of glucose by the charcoal. This method is employed
largely for the purpose of distinguishing between lactose and glucose.

Acetone. — ^Thc various tests for acetone, and tJicir chemistry, are
given by Hartley.^ . His special test is performed as follows : To ;io c.c.
of the urine add 2*5 c.c. of concentrated hydrochloric acid and 1 c.c,
of a I per cent solution of sodium nitrite. Shake and allow to stand
two minutes. Now add 15 c.c. of strong ammonia, followed by 5 c.c.
of a 10 per cent solution of ferrous sulphate or a solution of ferrous
chloride of. equivalent strength (2 grams of iron in 100 c.c.). Shake up,
pour into a 50 c.c. Nessler glass, and allow to stand undisturbed. It is
not advisable to filter. A beautiful violet or purple colour is produced.
The reaction is a slow one, and the speed at which the colour develops
depends on the concentration of the aceto-acetic acid in the urine ;
the colour deepens for several hours after its first appearance. The
explanation offered is that the aceto-acetic acid is converted by the
nitrous acid into isonitrosoacetone, which forms a salt with the
ammonia ; the ferrous salt then produces a purple-coloured salt from
the ammonia salt by double decomposition.

CH3CO.CH2COOH CH 3 C 0 .CH:N 0 H (CH3CO.CHNO) , Fe

Acetoacetic acid Isonitrosoacetone Ferrous salt

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URINE TESTS

It is delicate enough to detect acetone i>-5o,ooo. A modification
enabling a quantitive analysis to be made is also given.

Bonnamour and Imbert^ have modified Legal’s test. The reagent
consists of 10 grams of glacial acetic acid and 10 c.c. of i-io solution
of sodium nitro-prusside ; 20 drops of this are added to 15 c.c. of urine,
and then 20 drops of ammonia are allowed to float on as for a ring test.
A violet disc appears if 1-2000 part of acetone is present. Just as
“ acetone bodies ” in the urine are usually included with the acetone,
the same tests will be found to be employed for both. Thus, these
authors modified Gerhardt’s test as follows : dilute the urine four times,
and add a 10 per cent solution of ferric chroride drop by drop. If
acetone alone is present, a white cloudy precipitate forms, whereas
diacetic acid produces a black-violet cloud.

The fact that ordinary tests for acetone in the urine are usually
concerned really with the presence of acetone bodies in it, is brought
out by Piper,* who studied their appearance in the urine after operations
and certain diseases. He found that acetone is apt to appear after
operations in those persons endowed with a neurotic temperament.

Total Nitrogen and Ammonia-nitrogen , — Simplified methods for
estimations of these have been given by Rosenbloom.® For total
nitrogen, mix 2 c.c. of urine with 5 c.c. of concentrated sulphuric acid
and 5 drops of a i per cent solution of platinum chloride, and heat in
a Kjeldahl flask till the mixture is clear. Transfer to a 350 c.c.
Erlenmeyer flask, add about 100 c.c. water, 6 drops of neutral litmus
solution (Kubel-Tiemann), and 10 c.c. of a 30 per cent solution of
sodium hydroxide. Cool the flask in running water, and when it is
quite cold, gradually add more of the 30 per cent sodium hydroxide,
until the fluid is blue, taking care to keep it as cool as possible all the
time. Make the solution slightly acid with fifth-normal acid, and then
neutralize with fifth-normal sodium hydroxide. Add to this neutral
solution 15 c.c. of neutral formaldehyde, and i c.c. of i per cent
alcoholic solution of phenolphthalein. Titrate this with fifth-normal
sodium hydroxide until a violet colour appears. The number of c.c.
of sodium hydroxide solution, 0*0028, gives the amount of nitrogen
present in the 2 c.c. of urine. For ammonia nitrogen, lo^'c.c. of urine
are diluted with about 50 c.c. of water ; three drops of '"a 1 per cent
alcoholic solution of phenolphthalein and about 5 grams’^of powdered
neutral potassium oxalate are added. Decinormal sodium hydroxide
solution is added from a burette, and the reading taken when a
permanent faint pink colour appears. Five c.c. of a neutral solution
of formaldehyde are then added, and it will be found that the pink
colour will disappear. The addition of decinormal soda is continued
till the pink colour of the mixture is just restored, and the reading is
taken again. The difference between the first and second readings
gives the amount of acid that was combined with ammonia, and this
X *0014 gives the quantity of ammonia-nitrogen in 10 c.c. of urine.

Oxy-pYOtein-acid-nitrogen , — ^The variations of this form of nitrogen
are given by Erben.® Roughly it amounts to about i per cent of the

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MEDICAL ANNUAL

non-precipitable nitrogen. It does not run parallel with the aminO'-
acid secretion. Oxy-protein-acids precipitated from acid solution by
mercury acidate are increased in certain diseases of the liver, in some
infectious diseases and pernicious anmmia, as well as in cancer.

Albumin . — Discussing the relation between albumin content and
the amount of pus in the urine, Warren’ says that the most marked
cases of cystitis show no more than *15 per cent of albumin. If the
urine be free of blood and there is more than this percentage of albumin,
one may be sure that the pus comes from the kidney. If there be a
very little pus and yet the albumin content is *15 per cent, it is very
likely that the kidney is involved.

Organized Sediments . — ^The need for noticing the existence of any
kind of cast in the urine is strongly brought out by Thornton. He
considers that even hyaline casts should be looked upon as indications
of senility, regardless of the patient's age in years. The real difference
between granular, hyaline, and fatty casts remains unknown. He
cites a case in which the linding of casts with crystals of calcium oxalate
in the deposit proved the incorrectness of a diagnosis of appendicitis,
and directed attention to the existence of a stone in the kidney.

Bie^ gives the following stain for tmnary sedimsnfs : Twenty c.c. of
•2 per cent crystal violet and 5 c,c. of glacial acetic acid are added to
75 c.c. water, and the deposit is mixed with an equal volume of stain.
Hyaline casts come out a pale violet, bacteria and nuclei a deep violet,
and other casts darker lilac.

Bacieviuna is discussed by Hale White.’® He refers to the advantage
of isolating the organisms in question for the purpose of treating the
patients with autogenous vaccines.

Pigments. — Fischer”- gives a spectroscopic test for hemibilirubin.
The test is rather elaborate, and I'equires a large quantity of urine in
order to obtain enough pigment. Flatow and Briinell’^ give a test for
urobilinogen — red. Here again a colorimeter is necessary, and it is
hardly possible to carry out this test except in a si)ecially equipped
laboratory.

Ferments. — Corbett’® has elaborated a method of estimating the
amylolytic ferment in urine, thus : A series of test-tubes receives
successively diminishing quantities of urine, with 2 c.c. of *i per cent
solution of soluble starch. After warming on a water-bath at 38^^ for
half an hour, a drop of one-fiftieth-normal iodine is added, and the tube
in which a*mauve tint just appears is noted. The result is calculated
in terms of the number of c.c. of starch solution digested by i c.c. urine
in half an hour. The normal lies between ten and thirty. It is below
normal in diabetes, and very high in chronic pancreatitis and eclampsia.
An increased ratio between the urine contents of the ferment to that
in the blood means less of renal efficiency.

References ii> 859; ^Ibid, i, 1160; ^Presse Mid. 1913,
130 ; ^Lancet, 1913, ii, 535 ; ^Jour. Amer. Med. Assoc. 1913, ii, S7 ; ^Prager
med. Wooh. 1913, No, 2 ; W.y. Med, Jour. 1912, ii, 1228 ; ^Lancet, 1913, i,
15S3 ; ^Ugeskr.f. Lager, igi2. No. 26; ^^Lancet, 1912, ii, 1204; ^^Mtinch. med.
Woch, 1913, 2555 ; ^^Ibid. 234 ,* ^^Quart. Jour. Med, 1913, Apr/ 35T,

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URTICARIA. E. Graham Little, M,D„ FM.C,P.

Swann^ has found immediate benefit in urticaria by giving sub-
cutaneous injections of Adrenalin Chloride (i-iooo) in doses of 8 min.
for every ten stone of the patient’s weight, this dose being repeated
ten minutes later. Two doses usually sufficed to control an individual
attack ; but the eruption tends to reappear from two to three hours
after the injection. The author suggests trial of the medication in
acute cases of angioneurotic oedema which, when it affects the air-
passages, may threaten life itself.

The development of urticaria in young children changing from the
country to the town is noted hy Letchfield,^ who ascribes it as probably
due to change in water supply.

References. — ^Aniev. Jour. Med. ScL 1913, i, 373 ; -Austval. Med. Gas.
1913^ 301 -

UTERUS, DISEASES OF. Victor Bomiey, M.S., M.D., B.Sc., P.R.C.S.

Bryden Glendining, M.S., F.R.C.S.

Cancer. — Lenormant^ describes in detail the results of cystoscopic
examination of cases of carcinoma of the cervix under the following
headings : bulgings of the bladder wall, displacement of the tiigone,
puckerings of vesical mucous membrane, oedema of the mucosa, actual
invasion of the mucous membrane by growth. These conditions are
met with in other diseases, are of no value in the diagnosis, but are
helpful in showing the operability of the case. He considers that
puckerings of the mucous membrane are caused by tight adhesions,
and injury to the bladder Avail during operation is likely to be done.
Puckerings and oedema of the mucous membrane are usually due to
adhesions of the growth itself, and therefore make the operation
dangerous, if not useless. He also found that compression of the
ureters is common, but that actual invasion by growth is rare.

Howard Kelly and Craig Neel,^ from a study of cases treated at the
Johns Hopkins Hospital, find that Extensive Abdominal Removal
of all cervical carcinomata is justified where there is any hope of
complete excision, unless there is some special contraindication to
surgical treatment. The operation, if properly performed, notwith-
standing the higli primary moi*tality, has given the greatest percentage
of permanent cures of any therapeutic measure thus far suggested.
By improvement in technique the primary mortality has been deci-eased
from 28*5 to 1 1 '5 per cent. An exploratory laparotomy is often
necessary to determine if a case is operable. Decreased mobility
of the cervix is sometimes due to a secondary inflammatory reaction,
and may be improved by a thorough cauterization of the growth.
Preliminary cauterization and disinfection of the primary growth are
advisable in all cases. Preliminary catheterization of the ureters is
a valuable aid, especially in fat patients, and does not necessarily
increase the probability of fistulse and secondary infection of the urinary
tract. Extensive glandular dissection is not justified, since the increase
in permanent cures does not compensate for the rise in the primary

UTERUS

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MEDICAL ANNUAL

mortality. They consider Radium, used in large quantities (loo to
200 mgrams at a time), to be of great value in cases which are in an
inoperable condition, and in early recniTcncc after operation. It may
be used with a view to effecting a cure of the disease in inoperable
cases ; before operation, with a view to rendering innocuous any small
foci of disseminated cancer cells which might not have been extirpated,
and would rapidly cause recurrence ; or at the end of operation, to
destroy any cancerous cells left at the base of the broad ligament, or
in cases in which the operation ha.^ been deliberately conducted through
diseased tissues, relying on radium to destroy them. It may also be
applied after operation in cases of early recurrence in the vaginal vault,
or ill the remains of the broad ligaments.

Faure^ states his conclusions drawn from a series of 250 operations
for cancer of the uterus since 1896. In early cancer which only involves
one lip of the cervix, leaving the mobility of uterus unimpaired, the
operative mortality does not exceed 5 per cent. He has cures of eight,
ten, and fourteen years’ duration. When both lips, the vaginal mucosa,
and the base of the broad ligaments are attacked, with diminished
mobility of the uterus, the operative mortality is about 20 per cent ;
and in only 50 per cent is there a permanent cure. When the uterus is
almost fixed and invasion of the broad ligaments extensive, the opei*a-
tive mortality is 50 per cent, and recuirence is the rule. I'he operative
mortality of his whole series was 15 per cent, with 33 to 40 per cent
permanent cures. He prefers Wertheim’s abdominal to Schauta’s
vaginal operation, limiting the latter to very cachectic or obese cases ;
Wertheim’s operation is more easily performed in pregnant patients.
He thinks that radium should not be used before operation, owing to its
sclerosing action on tissues, but finds its application three weeks after
operation very useful.

Childe,'* in a paper on a new- method of performing Wcrlheim’s
panhysterectomy, says that metal retractors should be avoided, as they
injxire the edges of the wound ; the only retractor should be a gloved
finger. The vagina and cervix are cleansed at the beginning of the
operation after the patient is amesthetized ; all growth is out or scraped
away, the raw surface is cauterized by a Paquelin cautery, then carefully
dried and painted with a 2 per cent solution of iodine in spirit, and the
vagina tightly packed with dry sterile gauze, which is removed when
the vagina is about to be divided. Perfect hamiostasis is essential ;
this he secures by cauterizing the parametric tissue and the cut vaginal
surfaces with a Paquelin cautery.

Sampson^ reports the results of the radical abdominal operation for
cancer of the cervix in 25 cases. Only 8 had been operated upon
five years or more ago ; of these, 2 died from the operation and 2
from recurrence within .five years, while 4 are still alive and — as far as
clinical examination can make out — are quite free from cancer.
Cullen‘S discusses the technique and results of the same operation in a
large number of cases. He considers that Wertheim’s operation is
the most satisfactory, and that surgeons should operate when there is

NEW TREATMENT

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UTERUS

the slightest chance of cure, in view of the terrible death which occurs
in patients not operated upon. He also makes a plea for the education
of women in America with regard to the dangers of allowing vaginal
haemorrhage at or about the time of the menopause to be neglected.

Werder,^ describing the treatment of cancer of the cervix uteri by
the Cautery, says that he prefers the galvano-cautery to the Paquelin.
His first nineteen cases were done by the vaginal route only, but since
then he has used a combined vaginal and abdominal method. He
begins with a thorough curetting of the diseased surfaces, which he
next cauterizes to stop bleeding. The cervix is then pulled down, and
an incision made around it as far as possible from the growth, with the
cautery knife, kept at a dull red heat. The uterus and bladder are
carefully separated until the peritoneum is reached but not opened.
Douglas’ pouch is next opened and the lateral vaginal attachments
burned through. The vagina is then tightly packed with gauze. The
abdomen is now opened by a suprapubic incision and the utero-
vesical peritoneum incised. The infundibulo-pelvic ligaments are
divided by Downes’ electro-thermic clamp. The parametrium and
broad ligaments on each side are divided with the cautery, the ureter
and bladder being carefully protected ; occasionally the uterine arteries
have to be ligatured. The cut vaginal surface is then carefully cauter-
ized before closing the abdomen. He seldom removes lymphatic
glands. He has treated 78 cases by this method ; his operative
mortality has been 5 per cent. In 39 cases five years or more have
elapsed since operation, 18 of whom have survived ; but 4 of these
have since died of recurrence between five and six-and-a-half years
after operation, so that 14 only are still living. He considers that
accidents to bladder, ureters, and intestine are no commoner by this
method than by any other.

Amputation of the Cervix, — Leonard,® in a paper on the after-results
of this operation in 128 cases, says that haemorrhage after amputation
occurs in 5 per cent of cases ; it may be weeks after, and is then due to
infection rather than faulty suture. Persistent leucorrhoea of cervical
origin is cured in 60 per cent, and improved in about 30 per cent ;
80 per cent of the patients remain sterile after operation, owing either
to a narrowing of the external os or to stenosis of the cervical canal
from contraction of the scar tissue. A pregnancy after amputation
has not more than an even chance of going to full term, in which case
considerable difficulty will usually be met with, owing to the unyielding
scar tissue. Consequently, the operation should be avoided if possible
during the child-bearing period.

Intramural Abscess. — Harrigan® reports a case arising in the puerperal
uterus, treated by hysterectomy, with recovery. He reviews the
literature of 34 cases, all of which were puerperal. In 23 the abscess
was single, in 1 1 multiple ; 9 ended fatally.

Myoma . — Ellice MacDonald^® reviews the . results of treatment of
700 cases. He finds that the menopause does not cure fibroids, and
increasing age brings increasing danger from these tumours. There is

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M3SDICAL AKNUAL

little fear of malignancy in fibroids before the fortieth year, but the
danger increases with every year after that age. In twenty-seven
per cent the tubes arc diseased, so that they should be carefully
examined, and removed if necessary. In view of the various degenera-
tions which may take place in fibroids, they should be removed early
if causing symptoms.

Bland-Sutton^^ compares the results of the operation of abdominal
hysterectomy for fibroids and for cancer of the neck of the uterus. He
is of opinion that tlie explanation of the difference is simple and
interesting, and depends mainly on the bacterial 11 ora of the uterus.
In 1910 the operative mortality for operations for the abo\^e conditions
performed at seven London hospitals was 2*4 per cent and 16 per cent
respectively. He estimates that i per cent of patients who have
submitted to abdominal hysterectomy for fibroids die suddenly during
convalescence, from pulmonary embolism. This fatality is more
frequent after total than after subtotal hysterectomy, and tlie risk is
highest of all after abdominal liystereciomy for cancer of the cervix
uteri. He considers that the emboli frequently arise from the deep
epigastric veins, which may become thrombosed from damage with
metal retractors or from infection spreading from buried sutures in the
abdominal wall ; he thinks that the infection of the sutures is due to
the surgeon’s hands becoming infected by touching the cervical canal
after amputation of the uterine body. The cervical canal is sterile in
the majority of women, especially virgins ; but in parous women with
patulous cervices, various organisms are present. He guards against
this danger by swabbing out the canal with iodine in subtotal hyster-
ectomy, and in total hysterectomy by swabbing the cut edges of the
vagina.

KiiFERENCEs. — "^Pycssc MM, 1913, 427 ; '^Johns Hop. Ho.^p. Bull. 1913,
231 : ^^SuYg. Gyn. and Obst, 1913, i, 290 (abst.) ; '*Bnf. Med. Jour. 19x3. ii 721 ;

Gyn. and Obst. 1913, i, 304 ; ^Ibid, 265 ; Ubid. 272 ; *^Jbid, 390 ; ®AM',
Med, Jour. 1913, i, 444 ; ^^^Amer. Med. 1913, i, 161 ; MM. Jour. 1913,

i, 205*.

UTERUS, DISPLACEMENTS OF.

Victor Bomiey, MS., M.D., BSc., F.R.CS.

Bryden Glendimng, M.S., F.R.C.S.

Reirojiexion. — Donald and Fletcher Shaw^ maintain that the sym-
ptoms associated with retroflexion, such as menorrhagia, metrorrhagia,
dysmenorrheea, pelvic pain, miscarriage, and sterility, are not clue to
the displacement, and all that is required to cure these symptoms is
dilatation and curettage. Any fixation operation is unjustifiable
unless curettage has been tried and twelve months have elapsed since
the trial. In all cases in which curettage fails, some condition other
than simple retroflexion will be found.

Figuero^ describes a method of Shortening the Round Ligaments
for retroflexion and retroversion, which he claims is superior to those
at present in common practice. It consists in dissecting out the round
ligament in the inguinal canal just over the internal abdominal ring ;

NEW TREATMENT

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UTERUS

a loop of the ligament is pulled up and stitched to the posterior sheath
of the rectus. The advantages claimed are that the operation is extra-
peritoneal, and the ligament is shoitened at the expense of the weak
distal portion. The disadvantages are that two incisions are made
instead of one ; if the uterus is adherent in the pouch of Douglas, the
operation is useless ; and if the ligaments are thin and atrophied, the
operation is of little value.

Prolapse of Uterus and Vaginal Walls. — W. J. Mayo® reviews the
results of operative treatment in 629 cases, which he divides into three
classes, the treatment varying with each, (i) In patients during the
child-bearing period, usually with supravaginal elongation of the
cervix, there is usually little cystocele or rectocele. The operations
generally performed are amputation of the cervix, and extraperitoneal
round-ligament shortening combined with perineorrhaphy. Occasion-
ally the utero-sacral ligaments are shortened too. (2) In patients
from forty -five to fifty -five years of age, and unlikely to bear children
again, cystocele is the most marked feature. They are usually treated
by the vaginal fixation operation of Wertheim, in which the bladder is
separated from the vagina and uterus, and the uterus is then acutely
ante verted and fixed between the vagina and bladder. Amputation
of the cervix is often combined with this operation. This cannot be
done when the uterus is atrophic. (3) For patients past the meno-
pause, with atrophic uteri and procidentia, he removes the uterus,
ovaries, and tubes, and fixes the upper part of the vaginal wall to the
cut ends of the broad and round ligaments. He calls this “ vagino-
pelvic fixation,'' and has obtained very good results from it.

Ventrofixation. — At a discussion at the Royal Society of Medicine ^
Griffith considered the following indications for this operation. Class I,
contains cases in which the uterus is retr overted. Ventrifixation may
be called for if the uterus is more or less fixed by adhesions, or pressed
down by a tumour, usually ovarian, in a position of retroversion ; or
after a fibroid has been enucleated ; or when retroversion is compli-
cated by prolapse and enlargement of the ovaries (a constant
source of pain unrelieved, and in some cases increased, by the pressure
of a pessary) ; or when the retroverted uterus is not kept in position
by a pessary owing to the small size of the cervix or the dilated condition
of the vagina. Class II. comprises patients with prolapse of the uterus
and vaginal walls, with great enlargement of the vaginal orifice. The
operation is usually done after curetting and perineorrhaphy or colpo-
perineorrhaphy.

Giles described his operation, which he calls Hysteropexy. He
had performed it in 508 cases, 368 of which he had been able to trace.
He found that in over 90 per cent of these, the general health was
improved and the symptoms were relieved ; that the position of the
uterus was uniformly good in 95 per cent ; that hysteropexy when
followed by pregnancy caused no complications in labour ; and that
pregnancy after hysteropexy did not disturb the position of the uterus.
Of his last 200 cases, 46 per cent were for retroversion, 20 per cent for

UTERUS

Ml^DlCAL ANNUAL

6t>4

prolapse, and 33 I'or procidentia. In the last two groups he combined
it with some operation lor vaginal repair.

Spencer had only done the operation 27 times in jooo abdominal
sections. He considers veulrolixation and va^ulrosuspeusion, as
usually perloianed, dangerous and unscienlihc operations, giving rise
to peritoneal bands, which had many times led to strangulation of the
bowel. For procidentia after the menopause, he considered the
operation a useful adjunct to colporrhaphy and perineorrhaphy^, but
care should be taken to close the peiiloneum completely over the
bladder. Hubert Roberts considered that the greater number of
cases of backward displacement did not require operative treatment.
He had done the operation in a few cases when symptoms were
definite, selecting Gilliam's method in young women, and ventrofixa-
tion in women past the child-bearing age,

Tate had performed the operation in .pi cases ; in 25 the after-
history had been obtained, and seven had borne one or more children
without any complication either in pregnancy or labour. He tliought
this good result was due to the fact that the fixation sutures were
passed through the lower part of the uterus, leaving the fundus free.
He only advised the operation in cases where pessaries and other
methods failed to relieve symptoms. He had also found the ojDeration
useful in some distressing cases of incontinence of urine due to weakness
of the bladder sphincter. He explained this on the ground that by
fixing the uterus the neck of the bladder was also supported.

References. — ’^Pmet. 1913, i, 961 ; '^Jouv, Amey. Med. Assoc. 1913, i,
1042 ; 1912, ii, 1421 ; Med. Jour, 1913, i, 713.

YACCINATION. E. W. Goodalh M.D.

Barach^ draws attention to cases of what he and others believe to be
a local anaphylactic phenomenon in vaccination. In this a primary
vaccination is performed* and cither fails or the local reaction is feeble.
After a time another vaccination is done, which is successful. At or
nearly at the same time as the lesions appear at the site of rcvaccination,
similar lesions appear at the site of the primaiy vaccination. This
phenomenon (which seems to be the equivalent in man of Arthus'
phenomenon in the rabbit) is not common.

Reference. — '^Jouv. Amer, Med. Assoc. 1913, i, 569.

VAGINAL SARCOMA. Victor Bonney, M.S.. M.D., B.Sc\, F.R.C.S.

Bryden GUndinin^, M.S., P.R.C.S.

Bland^ describes two cases of sarcoma of the vagina, one occurring
in a child aged 2 J years, the other in a multipara aged 45. The tumours
were removed, but in each case the patient died from recurrence in less
than six months. Both growths were round-celled in type. He
considers sarcoma of the vagina to be a very deadly type of new growth,
and regards as essential a careful examination under anaesthesia of all
infants suffering from discharge from the genital tract.

Reference. — '^Jour. Amer. Med, Assoc, 1912, ii, 509.

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VENA CAVA INFERIOR

VARICOSE VEINS. PHestley Leech, M.D., F.R,C,S.

Geinitz, of Garre's^ clinic in Bonn, publishes the results of the
treatment of six cases by spiral incision of the skin. Friedel,®
Kayser,® and Bercher ^ have recorded very favourable results
obtained by this method. Geinitz was not pleased with the
immediate results, but in seeing the cases a year and a half later
found all but one very improved and relieved. He recommends
the operation in cases where there are numerous diffuse varices for
which the ligature of a vein is not suitable. Where there is atrophy
of the skin, or thrombosis of the deep veins, the operation is not to
be recommended.

Saphenous-femoral Anastomoses. — ^Weichert, of Breslau,® reports
five cases in which he made an anastomosis between the saphena vein
near its opening into the femoral vein and the femoral artery. The
saphena was divided, and implanted into the artery. The final results
were not so good as were expected, and not such as corresponded to
the difficulty and magnitude of the operation. The improvement was
slight ; the swelling diminished, the ulcers have healed, the cramps in
the calf are less, and the walking is easier.

References. — ^Munch. med. Woch. 1913, June 10; ^Aych. f. klin. Chir.
1908, Ixxxvi ; ^Bmns' Beit. z. hlin. Chir. igio, Ixviii ; ^Zentralb. f. Chir.,
1911, No. 13; ^Bevl. hlin. Woch. 1913, 1396.

VENA CAVA INFERIOR, THROMBOSIS OF.

Carey Coombs., M.D., M.R.C.P.

From the cases reported by Shattock,^ Parkes Weber, ^ and Willett
and Maechtle,® several facts of practical importance emerge. In the
case of the last named, pregnancy or the puerperium, or both, appeared
to be responsible for the lesion ; one of Weber’s cases was manifestly
due to typhoid infection ; while in his other, and in that described
by Shattock, an injury was to blame. In the former the injury was
from without, in a carriage accident ; in the latter it was internal, and
due to the excessive intravenous strain of a 120 yards hurdle race.
The possibility of a traumatic origin has an obvious medico-legal
significance.

It is also important to realize how favourable a course this apparently
serious malady may run. Shattock’s patient lived twenty-hve years
after his accident, dying eventually of septicaemia, while Weber’s
patients, seen ten and seven years respectively after the first examina-
tion, showed no signs of advance in the affection. The woman seen by
Willett and Maechtle was able to resume her household duties without
inconvenience. The presumption is that, granted an efficient collateral
circulation, a patient can do passably well without his inferior vena
cava. This should be remembered in connection with life insurance
and other prognostic problems.

References. — '^Brit. Med. Jour. 1913, i, 385 ; ^Miinch. med. Woch. 1913,
1434 ; ^Jour. Amer. Med. Assoc. 1913, ii, 1878.

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MKDICAL ANNUAL

YERRUGA PERUANA. Leonard Rogers, M.D., F.R.aP.

H. N. Cole^ has studied the comparative histology of this disease in
man and in apes. He failed to find any of the numerous supposed
parasites of the disease which have been described by different workers.
Monkeys could be infected by inoculation from the local lesions, so they
are probably due to an undiscovered parasite. The tumours are granu-
lomatous in type, characterized by dilatation of the lymph-vessels,
choking with mono- and polymorphonuclear leucocytes, and surrounded
by a cellular infiltration ; and extravasation of red corpuscles.

Reference. — ^Jonr. Cutan, Dis. 1913, 384.

VERTIGO. (See also Labyrinthitis.) Geo, L, Richards, M,D,

Vertigo and Labyrinthine Disease, — Lake^ considers chronic progres-
sive middle-ear deafness and arteriosclerosis the cause of the majority
of cases of aural vertigo, which may be divided into three causative
classes : (i) That due to peripheral causes (chronic middle-ear deafness,
haemorrhage and embolism into the labyrinth, and traumatism) ;
(2) That due to increased or diminished blood -pressure ; (3) Vertigo
due to general systemic causes, such as leukaemia, from casual or
occasional causes like gout or gouty dyspepsia, specific causes, cerebral
anaemia simulating aural vertigo, and vertigo combined with ocular
symptonis. A large majority of cases arising from peripheral causes
or arteriosclerosis find relief from the use of drugs. Operation is only
justifiable when the deafness is of negligible quantity, and the accom-
panying tinnitus and vertigo make the patient’s life intolerable. The
operation is certain to obtain relief for the patient, and has no risks.
He places but small reliance on the rotary and caloric reactions, and
finds that both diagnosis and prognosis can be made equally well
without their employment. With reference to increased labyrinthine
pressure, although he has treated at least 20 cases of labyrinthine
vertigo where there had been no perforation into the labyrinth, and in
14 of which where there had been no previous suppuration, in only
2 cases did he see any fluid on opening the labyrinth. In these there
was a considerable amount of fluid, and one had an extremely large
external semicircular canal. Even here he is not prepared to say that
the fluid was under pressure ; in fact he thinks it difficult to under-
stand, from a purely mechanical point of view, how fluid can be retained
under pressure in such a non-vascular, bony cavity as the labyiinth.
He has found cases of labyrinthine hsemorrhage to be absolutely
beyond the reach of medicines. In labyrinthine cases, Pilocarpine
should be tried, increasing the dose as rapidly as is consistent with
safety, and continuing it for about two weeks. In arteriosclerotic
cases, he confines himself to Hydrobromio Acid, with a small dose of
Quinine or Iodide of Potassium. In the so-called Meniere’s disease,
he uses small doses of quinine with hydrobromic acid.

Milligan^ considers the Operative Treatment of labyrinthine vertigo
in non-suppurative diseases of the internal ear, and limits surgical
intervention to such cases as have failed to respond to prolonged

NEW TREATMENT

667

VISCEROPTOSIS

general and local treatment, and to those in which it is necessary to
secure rapid destruction of a very excited and irritable labyrinth, as
determined by caloric and other tests. Post-operative increase of
deafness hardly requires consideration, as with an increase of irritative
symptoms there is a progressive loss of hearing, in addition to which
the amount of hearing at the time of tlie contemplated operation is,
as a rule, so small as to be almost a negligible quantity. In careful
hands the risks of facial paralysis are not great, provided that the field
of operation is kept thoroughly well illuminated, that some form of
labyrinth chisel (e.g., Lake’s) is used to open the semicircular canals
and the cochlea, and that no attempt is made to lever out pieces of
bone, utilizing the body wall of the Fallopian aqueduct as a fulcrum.
The destruction of the terminal filaments of the vestibular nerve
should be as thorough as possible. The more thorough the operation,
the less the amount of post-operative shock. For this reason, a
complete opening up of the external semicircular canal and of the
ampullary orifice of the posterior canal is advocated in order effectually
to destroy the peripheral terminations of the vestibular nerve. When
tinnitus is not much complained of, and when it is worth while attempt-
ing to preserve whatever auditory function is still left, operative
interference should be limited to the opening up of the external semi-
circular canal and vestibule after the performance of an ordinary
Schwartze operation.

Bradburne® finds that the examination of afected cases of disease
of the labyrinth shows that in a majority there is an ocular disturbance
in the maintenance of parallehsm of the vertical meridians ; that
when disease tends to invade the deeper parts in the neighbourhood
of the auditory organ, an ocular imbalance follows, which is manifest
in a difference in the elevation of the eyes.

References. — ^Ann. Otol. 1912, Dec. ; ^Laryngology, 1912, Oct. ; ^Bnt,
Med, Jour. 1912, Oct.

YISCEROPTOSIS. Robert Hutchison, M.D., F.R.C.P.

Pathology. — Lynch, ^ in a paper on gastroptosis and coloptosis
transversa, as seen in post-mortem examinations, arrives at the follow-
ing conclusions as to their etiology: That they are secondary and not
primary conditions ; that the underlying cause in both is a weakening
and relaxation of their supporting structures consequent to some
wasting disease, supplemented materially in the case of the colon, and
to a less extent in that of the stomach, by an actual myasthenia of
their walls, allowing an accumulation of contents ; that the emaciation
is primarily the cause of the conditions, but the establishment of a
vicious cycle is likely if the prolapse interferes with the digestive
function ; that the high percentage of occurrences of these conditions
frequently seen in literature, is not borne out by post-mortem examina-
tion.

Treatment. — ^T he advisability or otherwise of operative treatment in
visceroptosis is still much disputed. J. W, Smith,® in a paper describing

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668

MEDICAL ANNUAL

operations which he has performed for displacement of the intestine
(enteroptosis)* regards it as a condition which largely escapes recogni-
tion in practice, and makes the surprising statement that he cannot
remember a single instance where a case has been sent to him with a
diagnosis of enteroptosis. They come usually as gastric or duodenal
irritation or ulcer, floating kidney, suspected gall-stones, or as vague
cases with a view to diagnosis/’ He employs various operations for the
relief of the condition — appendicectomy, ileo-colostomy, and intesti-
nal resection — but unfortunately omits to state what the final results
of these procedures has been as regards permanent cure. Roosing,®
dealing with “ gastrocoloptosis,” puts in a plea for gastropexy, and
describes in detail the technique of the operation as performed by him.
Lund,^ writing also from the surgical point of view, is much more
conservative. What, he asks, is the practical surgeon to make of the
mass of contradictory writing about intestinal stasis, ptosis, and the
like ? In the first place, a wholesome respect for the human organism
as a whole, and the realization that dietetic, medicinal, and gymnastic
measures directed to the whole body are to be adopted in the majority
of cases. He will not admit that in ptosis, per sg, surgical treatment
is in place at all. Operation is called for only by symptoms. These
cases are most difficult, and demand careful individual study. Sur-
geons must be particularly careful in interpreting and reporting their
end results. Cures will be rare, but even relief is a good deal. Conser-
vatism and candour in reporting results are to be desired, as well as
optimism and courage in proceeding with the work. With these
opinions most experienced clinicians will agree.

References — ^N.Y. Med. Jour, 1913, i, logo; ^Med. Chron., 1913, May,
53 ; ^Ann. Surg. 1913, i, i ; *Bost. Med. and Surg. Jour. 1913, ii, 18 1.

YOLKMANN’S PARALYSIS. (See Myositis, Ischaemic.)

WHOOPING^-COUGH. (See Pertussis.)

YAWS. Leonard Rogers, M.D., F.R.C.P.

E. P. Stibbe^ discusses the old question of the relationship of yaws to
syphilis, and states that in Fiji the population are immune to the latter
disease, apparently as a result of suffering from yaws during childhood.
He therefore considers that the two diseases are related in some such
way as vaccinia and small-pox. [If this is so, inoculation of the
readily curable yaws should protect against the much more resistant
infection with the Spirochceta pallida. — L. R.]

Treatment. — R. P. Cockin^ records twenty cases of yaws rapidly
cured by intramuscular injections of o«6 gram Salvarsan in adults and
relatively smaller doses in children. Only one case required a second
dose, while two were chronic cases which had been unsuccessfully
treated for eighteen months in hospital by other methods. These
results are in accordance with former experience recorded in this
Annual.

References. — Afr. Med. Rec. 1912, 41S ; ^Jour. Trop. Med. 1912, 277.

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669

YELLOW FEVER

YELLOW FEYER. Leonard Rogers, M.D„ FR,C,P.

A. Agramonte^ writes on yellow fever as a strictly human disease.
He shows that the ^vhole of the subsequent history of Cuba confirms
the findings of the Reed Commission, and that there is no evidence
whatever that animals can be infected. There have been no cases in
Havana since September, 1908, in spite of a large non-immune popula-
tion. The only successful inoculation yet reported in animals was in
the case of a single chimpanzee, while other monkeys bitten by mos-
quitoes of proved infectivity produced no effect. By keeping a close
watch of all suspected cases and isolating them under mosquito cur-
tains, and fumigating the house to destroy all infected mosquitoes, the
disease has practically been stamped out of the whole of the large
island of Cuba.

J. H. White^ deals with the dissemination and prevention of yellow
fever at New Orleans. In the 1905 epidemic there, the prophylaxis
was based entirely on the findings of the Reed Commission. The
yellow-fever hospital was thoroughly screened against mosquitoes, but
no disinfection of fomites and fouled bed-linen, etc., of the patients
was attempted, and the laundry where they were washed was the only
institution in the city to escape yellow fever during the epidemic.
Patients were permitted to see their friends in hospital without danger,,
and no evidence of transmission of the disease, save through the female
stegomyia, which has bitten an infected person during the first seventy-
two hours of his fever, was obtained. The stegomyia is a purely
domestic mosquito, and will not fly more than a very short distance
in the open, so that fifty yards from an infected house is sufficient
protection, while houses on each side of an infected one often
escape. In preventing breeding of stegomyia, water-containers which
cannot be regularly emptied should be screened with wire gauze of
eighteen meshes to the inch, and small fish placed in permanent collec-
tions, Sagging roof gutters are a fertile source of mosquitoes, and
should be abolished in the tropics, the water being allowed to fall on to
the ground, as in the Panama Canal area. By isolating the sick in
screened houses, destroying infected mosquitoes by fumigation with
sulphur, etc., the 1905 New Orleans epidemic with 600 known cases
among a population of 335,000 was thus stamped out within three
months, at a cost of $325,000, or a fraction under one cent per head
per diem.

References. — W.Y. Med. Jour. 1912, ii, 465; ^ Amer. Jour. Med. Sci,
19x3, i, 378.

Part III. — Miscellaneous.

PUBLIC HEALTH;

Including

1. MEDICO-LEGAL AND FORENSIC MEDICINE,
tl. STATE MEDICINE (INCLUDING LEGAL DECISIONS).
III. INDUSTRIAL DISEASES AND TOXICOLOGY.

Edited by JOSEPH PRIESTLEY, B.A., M.D., D.P.H.

Medical O/yiccr of Health., Metropolitan Borough of Lainheth.

1. MEDICO-LEGAL AND FORENSIC MEDICINE.

Immunity of Trade Union Funds.

A case in the Edinburgh Court of Sessions again emphasizes the fact
that trade unions are exempt from actions in respect of any tortious
acts alleged to have been committed by or on behalf of such unions,
under s. 4 (i) of the Trade Disputes Act, 1906. The case was an
action for alleged slanders brought by an ex-ofhcial of the National
Sailors’ and Firemen’s Union of Great Britain and Ireland against the
Union and its officials and trustees. The action was dismissed with
costs.

Medical Unions registered under the Trade Union Acts would be
exempt in the same way and for the same reasons.

Liability of Panel Medical Oft'icer.

In the Liverpool County Council it was held, during 1913, that a
panel medical officer was liable to action in the ordinary legal Courts
for negligence or neglect of du.ty. An “ insured ” person claimed
against a panel doctor for a sum of money expended for medical ser-
vices by another medical man, owing to the refusal of the panel doctor
to attend. The County Court Judge entered judgment for the plaintiff
with costs.

The remedy for such a case as neglect or non-attendance is not only
that provided under Regulations made under the National Insurance
xAct — the so-called Disciplinary Regulations in connection with ‘ ‘ medi-
cal benefit,” or under the Act itself (s. 67 (2)), but also that provided
through the ordinary legal channels in use before the National Insurance
Act came into force.

Canvassing by Friendly Societies for Medical Officers.

An important decision was given in the case of Dr. Youatt v.
Wright in the Chancery Court for the County Palatine of Lancaster
at Liverpool, on Decembei i, 1913, The plaintiff complained that

PUBLIC HEALTH

671

MEDICO-LEGAL MEDICINE

the Friendly Societies’ Association of a certain district, through
their officers, without his consent, procured, by means of canvassing
and touting, persons (juveniles) as patients, in such a manner that, if
the same were done with the sanction or even acquiescence of the
plaintiff, it would amount to “an act of infamous conduct ” on his
part within the meaning of s. 29 of the Medical Act of 1858. The
plaintiff did everything he possibly could to prevent the canvassing
and touting on his behalf. The action was dismissed, the Court
stating that no relief could be given to the plaintiff, having regard to
the fact that the patients were juveniles who were treated as private
patients at the expense of the Friendly Societies concerned.

Garnisheeing of Fees due to Panel Medical Officers from
Insurance Funds.

It was decided in a County Court that a garnishee order must bo
issued, on application, against the fees due to a panel medical officer
from Insurance funds, but that the Court had power to return portion
of the arrested sum to such panel medical officer.

Operations under the Children’s Act.

An interesting point has been decided in connection with the Chil-
dren’s Act, 1908. Is a parent justified in refusing an operation upon
a child on the plea that such parent does not believe in operations ?
Is such a refusal neglect to provide adequate medical aid within the
meaning of the Act ? The Magisterial opinion has been expressed to
the effect that the parent was under no legal liability to allow an
operation to be performed. On appeal, however, the Court has taken
a different view, holding that, under the Act, in certain instances,
operations are necessary, but that such operations must be reasonable.
Each case must be decided upon its merits, due regard being paid to
the nature of the operation as well as to its necessity.

Workmen’s Compensation Act.

Several interesting decisions have been given during 1913 under the
Workmen’s Compensation Act, and these may, with advantage, be
put on record for convenient reference, as follows : —

I. Disease versus Accident.

{a). Appendicitis as an Accident , — This was the case of Drewster
i'. Bradford & Co. A workman, whilst at work, fell from a ladder a
distance of thirteen feet, complaining of having received an injury
therefrom. Some time afterwards, an operation for appendicitis was
performed upon him, and a tin-tack found in the appendix. The
man died, and his relatives claimed compensation. The County
Court Judge decided that death was due to appendicitis caused by a
foreign body (a tin-tack) being in the appendix, and that the fall* did
not “ light up ” the tin-tack. Vide Medical Annual, 1912, 593, and
1913, 578.)

(&). Pneumonia as an Accident , — This was the case of Walls or
Dryue and Others v. The Alloa Coal Company Limited. John
Drylie was employed in a pit, and whilst so employed contracted a
chill, which was followed by pneumonia, from which he died — thirteen

MEDICO-LEGAL MEDICINE

672

MEDICAL ANNUAL

days after contracting the chill. Whilst at work, water accumulated
at the pit bottom, and the deceased stood in cold water up to the knees,
with a draught of cold air pla^dng upon his body, for a period of about
twenty minutes. The pit was known in the trade as a wet pit. The
Sheriff-Substitute found that the pneumonia from which Drylie died
was due to the chill, which he contracted whilst at work, and that,
therefore, the death resulted from injury by accident arising out of, and
in the course of, employment. Compensation was allowed, and, on
appeal, the Sheriff-Substitute’s decision was upheld, with costs.

By this decision, death from disease may be an accident ” when
such disease can be definitely collocated in the relation of effect and
cause with some unusual, unexpected, and undesigned event arising
at an ascertained time out of the employment. If the conditions
under which work is carried out be normal, no claim for compensation
should succeed, such as in the case of John Brown v. The Gilbert-
field Colliery Limited. John Brown was at work in a mine, and
the work -was stopped owing to a wreck in the shaft, the men being
ordered up to the pit head by another shaft, but being kept waiting in
a cold draught for about an hour and a half. Brown contracted a
chill, pneumonia ensued, and the man died seven days after contracting
the chill. The Sheriff-Substitute awarded compensation, but, on
appeal, his decision was revei-sed, on the ground that there was nothing
abnormal in the circumstances in which the deceased found himself.

2. Miscellaneous Points.

(a) . Court of Session , — That in making a post-mortem examination
with a view to finding out the cause of death (whether due to an accident
as alleged or not), a medical man did not act illegally, whilst the
deceased’s relatives’ feelings were not really hurt, as such relatives
caused further examinations to be made of the dead body by indepen-
dent doctors, on account of the first doctor’s examination showing
that death was not the result of an accident.

(b) . Court of Session . — That a complainer is entitled to, and must
be furnished with, a copy of the report of the doctor who examined
such complainer on behalf of the employers.

PUBLIC HEALTH

673

STATE MEDICINE

IL STATE MEDICINE, INCLUDING LEGAL DECISIONS.

Bacterial Food Poisoning and Food Infections.

Food sometimes causes symptoms of poisoning (more or less severe)
in persons partaking of it, and the question of so-called ptomaine
poisoning has been discussed and reported upon from time to time.
The Local Government Board have, during 1913, published a report
on the whole subject, tabulating all the known outbreaks for years
past — >79 British and 44 Continental. The meat suspected is generally
in a made-up form, e.g., meat pies, sausages, brawn, etc. ; but other
articles of food have also given rise to similar outbreaks, e.g., sardines,
salmon, etc. The poison is the same in all — certain pathogenic organ-
isms or their spores or toxins, generally the Gaertner group of bacilli :
these may be of human or of animal origin, generally the latter, the
animals suffering from the disease due to the particular Gaertner or
other bacillus, or acting as “ carriers ” of such bacillus. The incubation
period varies, being longer or shorter according as to whether or not
toxins are present in small amounts. The symptoms are those of
gastro-intestinal irritation : pains in various parts of the body, rashes,
cramps, headache, giddiness, depression, and even coma and death.
The infectivity and case-mortality rates vary. The preventive measures
are : (i) Meat inspection at time of slaughter ; (2) Separation of

slaughter-houses and food-preparing places ; and (3) Cleanliness
generally.

Galvanized Iron Water Pipes.

An attack has been made recently upon the use of galvanized iron
water pipes, on the ground that the coating of zinc is so thin as readily
to suffer injury and a breach of continuity. The co-efficient of expan-
sion and contraction for each metal is different, so that the adhesion of
the one metal to the other is seriously affected if the pipe is subjected
to extreme variations of temperature. Soils act injuriously upon both
zinc and iron. Soft waters and waters containing inorganic impurities,
especially when slightly acid, attack zinc, iron, and lead quickly and
seriously. When the zinc of the inside of a galvanized pipe is dissolved
off in parts, electric couples are created, with the result that the dissolv-
ing process goes on more quickly, all galvanizing from the inside of the
galvanized pipe disappears, and symptoms of irritant poisoning from
the dissolved zinc show themselves in the consumers of the water
passing through such pipes. In Austria, it is stated, galvanized iron
pipes are not allowed to be used for water supplies.

Insect Porters of Bacterial Infections.

The Horace Dobell Lectures, given before the Boyal College of
Physicians, have crystallized existing knowledge on the subject of
insect carriers or porters of infection, e.g., house flies in relation to
typhoid fever, infantile diarrhcea, etc. In regard to diarrhoea epi-
demics, the following conclusions seem to be warranted : (i) The
fly-carrier hypothesis is the only one which offers a satisfactory inter-
pretation of the extraordinary dependence of the epidemic upon the
accumulated efiect of temperature ; (2) It offers a ready explanation

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MEDICAL ANNUAL

o[ the spread of infection to neighbouring children who have no direct
personal contact with the patient ; (3) I'hc peculiarities ol the relation
in time between fly prevalence and the epidemic in different localities
are not inconsistent with the view that fly-carriage is essential to
epidemicity.

Other matters dealt with in the Lectures are : (i) The transmission
of plague by fleas, and the mechanism by which the flea might infect
a healthy animal, the distribution of plague bacilli in the flea’s body,
the transmission of the plague bacillus from rat to rat, and from rat to
man through the flea of the rat, the importance of flea-transmission in
epizootics, etc* ; (2) The transmission of typhus by lice, and the

mechanism by which the louse might carry infection ; (3) The trans-
mission of African relapsing fever by the tick {Oniithodoros nwuhata)
and of the English, Russian, American, or Indian variety by some
insect not yet discovered ; (4) The transmission of poliomyelitis by
Stomoxys calcitrans (as stated by Rosenau, Anderson, and Frost).

The bed-bug [Chnex Icciiilarius) is suspected of carrying infection in
certain diseases, but the bulk of evidence is against such a theory.
There are no larval or pupal stages, the insect emerging from the egg
as a little bug ; again, a bug feeds, and then retires to some secluded
spot and slowiy digests the meal, wdiich it requires only at intervals of
several days ; and, finally, experimental transmissions have proved
negative in relapsing fever and typhus ; but, in the case of plague,
have proved positive, though there is no epidemiological reason for
supposing such a transmission takes place in nature to any extent.
Long intervals between meals, the lengths of time the insects retain a
meal, and the extent to wdrich it is digested before being excreted, are
points that may explain the reason why bed-bugs do not transmit
disease as do fleas and lice.

[See a/so Pellacu^a ; Poliomyelitis; Spirocilt^.to.sis, etc.)

Tuberculosis.

N otijicaiion. — All forms of tuberculosis (non -pulmonary as w'ell as
pulmonary) became compulsorily^ notifiable under the new^ General
Order of the English l.ocal Government J 3 oard, known as the Public
Health (Tuberculosis) Regulations, 1912, which came into force on
February i, 1913. More than half of the deaths from non -pulmonary
tuberculosis are those of children under five years of age, and it is
probable that a much higher percentage of the total number of persons
suffering from non -pulmonary -tuberculosis are children of that age.
Aliich good is expected to accrue from the notification of these cases,
not only in investigating sources of infection, but also in securing
improvement in the conditions under which the children live. Notifica-
tion is to be made on the strength of evidence other than that derived
solely from tuberculin tests, and the notification is : (a) Primary ;

and {b) Supplemental, Primary notification is to be made on a
special form to be supplied by the Authority, and is required in respect
of every case of tuberculosis, whatever organ be afiected, unless the
practitioner has reasonable grounds for believing that the case has been
already notified. Primary notifications are to be made by private
practitioners, district medical officers of Poor Law Unions, ^medical
officers of tuberculosis dispensaries, and medical officers of hospitals,
and school medical inspectois (the last-named on a special form).

PUBLIC HEALTH

STATE MEDICINE

675

The supplemental notifications have reference to admissions into,
and discharges from, Poor Law institutions or sanatoria, weekly.
The fees to be paid are set out in the Schedule to the Regulations, but
no accounts for fees need be sent in by the notifiers by filling up counter-
foils, as was formerly the case under previous Regulations and Orders,
which are revoked by the new Order.

These new (1912) Regulations consolidate and amend all previous
ones, and extend the compulsory notification to all forms of tuber-
culosis, so that pulmonary and non-pulnionary cases come under
official cognizance and administration. In this way, the notification
is brought into line with the “ Sanatorium " benefit of the Insurance
Act, which also deals with all forms of tuberculosis, and not, as is often
stated, with the pulmonary form only, i.e., phthisis. The field of
investigation is much widened, and the work of Sanitary Authorities
much increased ; for it is not expected that matters will stop at the
simple notification of the disease and the tabulation of statistical
results, but, on the contrary, the Local Government Board states that
patients’ homes are to be visited officially, and enquiries made with a
view to finding out, and dealing with, any conditions likely to cause
the disease to spread.

Tuberculosis in Milk . — During 1913. a new Tuberculosis Order has
been issued by the Board of Agriculture and Fisheries, and came
into operation on May ist. Under the Order, the Treasury will refund
to local authorities half the net amount payable by way of compensation
for animals slaughtered during a period of five years from the coming
into operation of the Order. The Order accepts, as a fact, that
tuberculosis is transmissible by the agency of milk used for human
consumption, and that, consequently, reduction of the number of
tuberculous bovine animals in the country must rediice the risk of
the spread of tuberculosis amongst the community. With this object
in view, an endeavour is to be made to destroy every cow found to
be suffering from tuberculosis of the udder or to be giving tuber-
culous milk, as well as all bovine animals which are suffering from
tuberculosis with emaciation. The forms of tuberculosis laid down
in the Order are definite, and may be extended hereafter by future
Orders as may be found desirable. For the present, however, it is
the wish of the Board that Local Authorities should proceed cautiously,
so as not to interfere with an adequate milk supply or disorganize
the important milk industry. Heroic measures taken at the present
time might defeat their own object. The terms of compensation are
definitely laid down in the Order, the animal slaughtered to be valued
in its condition at the time. Thus, if post-mortem examination
shows ]io tuberculosis, the compensation payable is to be the full
value of the animal, together with a further sum of twenty shillings.
If tuberculosis is found on post-mortem examination, the compensa-
tion payable is to vary with the extent of the disease found — the
less the disease, the more the compensation. Advanced tuberculosis
carries a compensation of one-fourth of the value of the animal or a
sum of thirty shillings (whichever sum is greater after deducting from
such sum qne-half of the costs of valuation and examination).
Tuberculosis which is not advanced carries a compensation of three-
fourths of the value of the animal after deducting one-half of the
costs of valuation. The Order also gives powers in respect of the

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MEDICAL ANNUAL

milk of suspected animals and the detention and isolation of such
animals whilst under suspicion. The Order applies to England and
Wales and Scotland, and a similar Order for Ireland came into
operation on June i, 1913. Much good must eventually be the
outcome of these Tuberculosis in Milk Orders, especially in the case
of children who suffer from tuberculosis of bovine origin — surgical
tuberculosis.

Venereal Diseases.

The International Medical Congress drew official attention to the
ravages of syphilis upon health, deploring at the same time the inade-
quacy of existing facilities for checking its dissemination, and suggest-
ing to all Governments concerned the following : (i) To institute a
system of confidential notification of the disease to a Sanitary Author-
ity wherever such notification does not already obtain ; (2) To make
systematic provision for the diagnosis and treatment of ail cases of
syphilis not otherwise provided for. There is, of course, no desire to
revive the objectionable Contagious Diseases Acts. The Government
quickly took the matter up, and appointed a Royal Commission on
Venereal Disease, under the chairmanship of Lord Sydenham, with
Mr. E. R. Forbes, of the Local Government Board, as Secretary.
The terms of reference are : to enquire into the prevalence of venereal
diseases in the United Kingdom ; their effects upon the health of the
community, and the means by which those effects can be alleviated
or prevented, it being understood that no return to the policy or
provisions of the Contagious Diseases Acts of 1864, 1866, or 1869 is, to
be regarded as falling within the scope of the enquiry.

In addition, the Local Government Board has issued a Report on
“ Venereal Diseases ” (published by Wyman & Sons, Limited), in
which it is laid down that the best method of controlling venereal
diseases and protecting those free from infection would be the provision
of means for cax'ly and accurate diagnosis, with skilled advice and
adequate treatment available for all infected persons. Particulars are
given of the arrangements at present available in England and Wales
for institutional treatment of these diseases — arrangements that are
wholly inadequate for the needs of the country, whether regarded
from the point of view of hospitals or of workhouse infirmaries. The
use of salvarsan and the application of the Wasserniann test should
not only be introduced, but systematically carried out, at all public
institutions. It is noteworthy that the Report expresses the opinion
that the time is not yet ripe for making venereal diseases compulsorily
notifiable, until a more reasonable attitude towards the whole question
has penetrated the popular mind.

Some authorities are already taking action in regard to diagnosis
of s^^philis, by offering the Wassermann blood-reaction test free of
charge for medical practitioners attending the poorer class of patients
in their districts. Outfits are provided for the purpose, and the test
is used both for diagnosis and for ascertaining the efficacy of treatment.

PUBLIC HEALTH

677

LEGAL DECISIONS

LEGAL DECISIONS.

The following legal decisions, given during I 9 i 3 » are important in
their relation to State Medicine and Sanitary Administration : —

I. Adulteration of Food and Drugs.

Anderson v. Britcher {King*s Bench Division).

Sale of Food and Drugs AcU 1875, s. 6 — Demerara sugar — Reference
to process used in trade.

Demerara sugar was demanded, and sugar grown in Mauritius,
consisting of cane sugar crystals coloured with an organic dye, was
given by the vendor. The magistrate held that '' Demerara sugar ”
had become a generic term referring to a process of manufacture, aiul
not to a place. On appeal, the Court upheld the Magistrate’s decision.

Appeal dismissed.

Grinible & Co. v. Preston (King's Bench Division).

Sale of Food and Drugs Act, 1899, ss. i9(2)-2o(6) — Vinegar — Pure
malt vinegar — Warranty — Failure to serve copy of Analyst's certificate.

^hnegar manufactureis gave a warranty (invoice) with vinegar that
they sold as pure malt vinegar. Analysis showed only 0*024 cent
of phosphoric acid. A copy of the analyst's certificate was not served
with the summons. The Justices convicted. Held, on appeal, that
as objection had not been taken to the non-service of the analyst's
certificate, the conviction was in order. Appeal dismissed.

Ross V. Helm (King's Bench Division).

Sale of Food and Drugs Act, 1875, s. 6 — Evidence and proof of appoint-
ment of Inspector — Purchase of whiskey sold to the prejudice of the
purchaser.

A sample of whiskey was found to be not of the nature, substance,
and quality demanded, and a summons was taken out against the
vendor, but was dismissed on the ground that the inspector did not
produce his appointment nor prove that he was a duly authorized
officer. On appeal, it was held, that it Avas not necessary to prove
that the appellant was an inspector in a prosecution under s. 6 of the
Sale of Food and Drugs Act, 1875, and further, that there was prim a
facie evidence that the appellant was, in fact, an inspector.

Appeal allowed and case remitted.

Marshall v, Skeit (King's Bench Division).

Sale of Food and Drugs Act, 1875, s. 6 — Milk deficient in fat —
Evidence of offence — Excess of fat in another consignment of same milking.

A sample of milk showed, on analysis, 26 per cent deficiency in
fat, and a summons Avas taken out against the vendor, who, when the
case Avas heard, put in, in evidence, that another consignment of the
same morning's milk from the same cows showed, on analysis, 3*1 per
cent excess in fat. The information was dismissed by the Justices,
but, on appeal, it was held, that, on the evidence of the analysis in
regard to the sample taken by the inspector, the Justices ought to
have con\dcted. Appeal allowed and case remitted.

LEGAL DECISIONS 678 MEDICAL ANNUAL

2 . Criminal Law.

Rex V. Pridmore {Coiwt of Criminal Af>peal),

Criminal Law — Evidence of common purpose— Two poachers lolth one
gun.

Night potiching by two poachers, one armed witli a gun and the other
carrying a stick, was interrupted by gamekeepers, one oi' whom was
shot in the face by the gun. The jury found both prisoners guilty of
shooting with intent to murder, but stated that they were unable to
say w^hich man fired the shot, but that the intention was to act with
a common puipose, viz., to prevent arrest. No evidence was given
at the trial of any arrangement, actual or implied, made between the
two poachers. On appeal, it was held, that the jury were justifted in
assuming a common purpose, viz., to prevent arrest, from the .actions
of the prisoners (the poachers) wJien pursued by the keepers.

A ppeal dismissed.

Rex V. Gross {Central Criminal Court).

Criminal Law — Intent to hill one person but actually hilling another
is manslaughter.

Prisoner went to a house for the purpose of killing with a shot from
a revolver a woman with whom her husband was ]i\’ing. Tlic husband
struck the prisoner, who, incensed thereby, fired at him, but killed,
by accident, the woman with whom the husband was living.

Verdict : guilty of manslaughter.

3. Drains and Sewers.

(n.) Kershaw v. Smith & Co. Ltd. (King's Bench Division).

Metropolis Management Act, 1855, ss. 85, 250 — Metropolis Manage-
ment Amendment Act, 1862, s. 64 — Drainage by combined operation —
Plan not carried out as approved by Local Sanitary A uthority.

Twelve houses and shops were allowed to bo drained in combination,
as shown on plan duly approved, after amendment, by the Sanitary
Authority. The plan was materially deviated from, whilst, in a<l(lition,
other drains were joined to the system ap}>rove(l on the plan. Tlui
irregularities came to the knowledge of the Sanitary Authority, who
served notice upon the original owner and builder under s. 83 of the
Metjropolis Management Act, 1855, for tlic alteration of the flrainage
in accordance with the plan as approved, as amended, originally. 'Jlie
notice was not complied with, and the Sanitary Authority 'did the
work themselves. Subsequently, a further notice was served upon
the respondents under s. 85 of the same Act, requiring the “ combined
drain ” to be taken up and all foul and polluted earth to be removed,
the combined drain " being a line of pipes which passed under the
respondents’ house, and which also took other drainage from neigh-
bouring houses. The Magistrate refused to make an order for the
notice to be complied with, and dismissed the information, with costs.
On appeal, it was held, that the line of pipes had been reinstated in
accordance with the plan as originally approved, as amended, prior
to the service of the notice under s. 85 of the Metropolis Management
Act, 1855, and that the “ combined drain ” was, therefore, a drain,
repairable by the owner or owners concerned.

Appeal allowed and case remitted.

PUBLIC HEALTH

679 LEGAL DECISIONS

4. Factories and Workshops.

Owner v. Beehive Spinning Company Lid. {King's Bench Division).

Factory and Workshop AcL 1901, ss. 32, 128, 137 — Abstract to be
fixed — Unnecessary to produce same in Court as evidence.

A summons re employment of young persons " contrary to the
Act was dismissed by the Justices on the ground that the abstract,
fixed in the factory, should have been produced as evidence in Court.
On appeal, it was held, that secondary evidence can be given of the
contents of a printed abstract, which is affixed in a Factory in accordance
with s. 1 28 of the Factory and Workshop x\ct, 1901, even though
notice to produce the said abstract has been given, as it is a document
which, b}’ s. 128, is required to be kept constantly affixed in the factory.

Appeal allowed and case remitted.

5. Housing of the Working Classes.

Ryall V. Ki dwell 6^ Son {Kings Bench Division).

Housing, Town Planning, etc.. Act, 1909, ss. 14, 15 — Landlord and
tcnajit — House reasonably fit for human habitation — Person with right
of action for injury sustained.

A defective bedroom fioor caused injiuy to a child, and an action
was taken against the landlords by the child, acting through her next
friend. The County Court Judge decided that the plaintiff, being a
stranger to the contract between landlord and tenant, had no right
of action. The plaintiff appealed, and it was held, that the plaintiff
was a stranger to the contract and, consequently, had no right of
action against the landlords. Appeal dismissed.

Middleton and .Wife v. Hall (King's Bench Division).

Housing, Town Planning, etc.. Act, 1909, ss. 14, 15 — Landlord and
tenant — House reasonably fit for human habitation — Person with right
of action for injury sustained.

Defective staircase caused injury to tenant’s wife, who took action
against the landlord to recover damages. The High Court held, that,
where premises are let to a tenant, and the tenant’s wife suffei's an
injury owing to such premises being not reasonably fit for human
habitation, the wife lias no cause of action.

Judgment for the Defendant,

Rex v. Local Government Board : Ex parte Arlidge (Court of Appeal).

Housing, Town Planning, etc.. Act, 1909, ss. 17 (6), 39 (x) — Local
Government Board Act, 1S71, s. 5 — Closing order — Refusal to determine
— Appeal to Local Government Board — Right of appellant to he heard.

This was an appeal from a decision of the Divisional Court dis-
charging an order nisi for a certiorari to quash an order made by
the Local Government Board. The Divisional Court held, that the
Local Government Board were not bound, before determining an
appeal under s. 39 (i) of the Housing, Town Planning, etc., Act, 1909,
to hear the applicant personally. On appeal, it was held, that the
Act intended the appeal to the Board to be of the nature of a Us inter
partes, and that the Board was bound to disclose to the appellant
all the evidence of fact placed before it. Appeal allowed.

LEGAL DECISIONS

680

MEDICAL ANNXTAL

6, Insurance Act.

{Divisional ConrL)

National Insumnce Act, 1911 — Man-nal lahoitv--— Lithographic artists
and engravers.

The Court held, that neither lithographic artists nor engravers,
though they did manual work, could be said to be engaged in “ manual
labour,*’ the work being really that of the brain and of the intelligence,
and that they were clearly within the exception in the Act.

Judgment for defendant.

Scottish Insurance Commissioners v. Royal Infirmary of Edinburgh
{Court of Sessions).

National Insurance Act, 1911, 5. i (i), (2), Schedule I., Pari I. {a ) —
Infirmary staffs and contract of service.

Held, that the following persons appointed to act in connection
with an infirmary are not persons employed within tlic meaning of
the National Insurance Act, 1911, the managers of the infirmary having
no control over the manner in which these persons carried out their
treatment of patients, and there being, in consequence, no contract
of service ” : {a) Resident physicians and surgeons ; {b) Non-resident
house physicians and house surgeons ; {c) Clinical assistants ; and
{d) Anaesthetists. Appeal dismissed.

7. Milkshops.

Spiers & Pond Limited v. Green {King's Bench Division).

Dairies, Cowsheds, and Milk Shops Order, 1885, Article 6 (i) — Regis-
tration of trade of purveyor of milk — Occasional sales not purveying.

The occupiers of a refreshment buffet at a railway station, selling,
amongst other things, two or tlxree glasses of milk per week, were
summoned before a Magistrate for not being registered as purveyors
of milk at such .station. The Magistrate convicted and imposed a
penalty (with costs) ; but, on appeal, it was held, that the appellants
were not carrying on the ti'ado of a purveyor of milk ” within the
meaning of the Order, owing to the .smallness of tlic sale and the fact
that the sales were occasional, and that, con.scc]ucntly, the appellants
did not require to be registered.

Appeal allowed and conviction quashed.

8 . Motor Cars.

Appleyavd v. Banghani {King's Bench Division).

Locomotives on Highways Act, 1896, 55. 5, 7 — Petroleum Regulations,
1907, rr. 2, 4 — Storage of Petroleum in store-house used as dwelling —
Petroleum in tanks of cars.

Regulation 4 of the 1907 Regulations (Petroleum) prohibits the
use of premises partly as a store-house for petroleum and partly as
dwellings. A stable had been converted into a motor garage and tlie
lofts above were used as dwelling-rooms, the intervening floor consisting
only of ordinary lath and plaster ceiling, broken in places, with wooden
beams across it. The rooms upstairs were approached by wooden
stairs from the inside of the garage, which were surrounded by a casing
of matchboarding. The petroleum stored was that stored in the
tanks of the motor cars. The Justices held that there was no storage ”

PUBLIC HEALTH

68i

LEGAL DECISIONS

within the meaning of the Regulations ; and, on appeal, the Court held,
that it is an offence against the Regulations to use as a dwelling-house
a loft having an unsubstantial floor situated above a garage in Avhich
are housed motor cars containing petroleum in their tanks.

Appeal allowed and case remitted,

Webster v. Terry (King's Bench Division),

Locomotives on Highways Act, 1896, 5. 2 — Motor Cars (Use and
Construction) Order, 1904, Article II, — Local Government Act, 1888,
s. 85 (i) — Red light visible behind on Motor Bicycles,

Held, on appeal, that Article II. of the Motor Cars (Use and Con-
struction) Order, 1904, applies to motor bicycles, requiring a white
light to be carried visible in front and a red light visible behind. A
motor bicycle is not a bicycle to which s. 85 of the Local Government
Act, 1888, applies. Appeal dismissed.

9. Offensive Trades.

Butchers' Hide, Skin and Wool Company Limited v. Seaconie
(King's Bench Division),

Public Health Act, 1875, s. 112 — Public Health Acts Amendment Act,
1907, 5. 51 — Offensive trade of raw hides — Establishment prior to Order
of Local Authority,

An offensive trade dealing with raw hides and skins was established
without consent in 19 ii in a certain borough, where s. 51 of the Public
Health Acts Amendment Act, 1907, was declared to be in force by
the Local Government Board. It was not, however, until 1912 that
the Board confirmed an Order of the Borough Council, declaring the
dealing in raw hides and skins to be an offensive trade. A summons
was taken out against the firm, and the Justices convicted, imposing
a fine and costs. On appeal, it was held, that the appellants were not
liable to a penalty for carrying on the business, inasmuch as at the
time wdien it was established its establishment was not unlawful.

Appeal allowed and conviction quashed.

10. Rag Flock.

(a). Gamble v. Jordan (King's Bench Division).

Rag Flock Act, 1911, s, i (i ) — Remaking mattress as against making
bedding.

Section i of the Rag Flock Act, 1911, requires that rag flock for
the purpose of making ” upholstery or bedding shall conform to
the standard of cleanliness prescribed by the Regulations of the Local
Government Board. Flock manufactured from rags was found on cer-
tain premises, and was proved to be not in conformity with the L.G.B.
standard. The flock had been taken fx’om an old mattress, and was
to be used again for re-stuffing or remaking ” the old mattress
without the addition of any other flock. The flock was shown to
contain 382*5 parts of soluble chlorine in the form of chlorides per
100,000 parts of the sample, i.e., 352*5 parts per 100,000 in excess of
the maximum allowed under the Regulations.

The Magistrate held that the '' restuffing ” or remaking of the
mattress was the making of an article of bedding within the meaning

LEGAL DECISIONS

G82

MEDrCAL ANNUAL

of the Act. On ai)pcal to llio High Court it was held, that the “ rc-
stiifting " or “ remaking ” of a mattress docs not I'onstitutc an offence
under the Act, provided that the Hock is simply taken out of the
mattress and put back without the addition of any other (lock.

Appeal allowed and convlctioii quashed.

II. School Medical Officers.

Symes v. Brown (King*s Bench Division).

Education — Non-attendance at school on account of verminous condition
[alleged) of other scholars — Reasonable excuse under bylaws.

Children were kept from school on the ground that there were
verminous scholars in attendance thereat, and that that fact was a
reasonable excuse for non-attendance under the liylaws. The
Justices refused to admit the reason assigned for non-attendance
as a reasonable excuse, or to licar evidence on the point; but it
was held, on appeal, that evidence must be taken to find if there wns
a reasonable excuse for the non-attendance of the children.

Appeal alloived and case remitted,

Rex V.- De Grey and A uothcr : Ex parte Eitogevahl
[King's Bench Division).

Elementary Education [Defective and Epileptic Children) Act, 1899,
5s. I (1), (3), Ti — Education [Administrative Provisions) Act, 1909,
5. 6 — Non-attendance of defective or epileptic child — Medical certificate
— Magistrates' power to examine a child.

The School Authority summoned a parent for not sending his
child to school ; a medical certificate was produced to the effect that
the child was not imbecile and not merely dull or backward, but was,
by reason of mental defect, incapable of receiving proper benefit
from the instruction in an ordinary school. The Magistrate examined
the child and then dismissed the summons, refusing at the same? tinu^
to state a case. On appeal, it was held, that the Magistrate was not
entitled to form his own opinion by questioning the child, but was
bound to act on the medical certificate, whicli was uot disputed.

Magistrate ordered U) state a case.

XI . Sewage Disposal.

Phillimore and Another v. Watford Rural Dislrict Council
[Chancery Division) .

Public Health Act, 1875, 4, 13, 16, 17 — Nuisance from sewage

farm — Right to discharge sewage effluent — Free right of passage and
running water.

A local authority purchased land for a sewage farm site — the purchase
to include the " free right of passage and running of water ” from
the land, so as not to create a nuisance to the vendor or his tenants,
A nuisance arose, and the vendor and his tenant entered an action
against the local authority before the High Court, when it was held,
that the fact that the land was sold to be used as a sewage farm site
did not preclude the plaintiffs from complaining of the discharge
of the effluent over their land so as to be a nuisance.

Judgment for the phdnUffs.

PUBLIC HEALTH

683

LEGAL DECISIONS

Hanley v. Edinburgh Corporation [House of Lords).

Nuisance from flooding of sewer due to insufficient culvert — Statutory
powers and dxities .of road and drainage authorities.

This was an action for damages from sewer flooding due to excep-
tionally hea\?y rainfall and insufficient culvert. The Lord Ordinary
(Scotland) gave judgment for the plaintiffs, but his decision was
reversed by the Second Division of the Court of Session. On appeal
to the House of Lords, it was held, that there was a statutory obligation
upon the Corporation to provide for the efficient drainage of the
burgh, and that they were liable to damages to the pursuer.

Appeal allowed.

13. Shops Act.

v. TL. H. Smith Son [King's Bench Division).

Shops Act, 1912, 5S. I (t), 14 (3), 19 (i) — Weekly half-holiday —
Liability of employer for assistant's infringement — Reasonable precau-
tions to prevent.

An assistant employed in charge of a book-stall at a railway station
refused to take a weekly half-holiday on the ground that the book-stall
was not a shop within the meaning of s. 19 of the Shops Act, 1912,
and that therefore he, the assistant, was not an assistant within the
meaning of the section. Further, the assistant contended that the
papers which he sold were sold on the platform, and not inside a
building or structure, as contemplated by the Shops Act, 1912. The
Justices dismissed the information, but stated a case for the decision
of the High Court, who held, that the case should be remitted for
further consideration, but that the occupier of a shop under the Act
commits an offence if an employee, in disobedience to instructions,
works in their business in the shop after the prescribed hour, unless
he show's that all reasonable precautions to prevent an infringement
of the Act have been taken, and that the actual offender has been
brought before the Court under s. 14 of the Act,

Appeal allowed and case remitted.

Williams v. Gosden.

Shops Act, 1912, 5. 4 (r), (6). and Second Schedule — Weekly half-
holiday — Exemption — Sales to travellers.

By s. 4 (6) of the Shops Act, 1912, and the Second Schedule to the
Act, certain trades are exempted from the provisions of a weekly
half-holida5L including the following : the sale of motor, cycle, and
aircraft supplies and accessories to travellers.” A case came before
the Justices, and was dismissed, on the ground that the exemption
referred to all supplies and accessories to travellers, whether by motor,
cycle, and aircraft, or not, and that, consequently, the trade of a saddler
or harness-maker selling supplies and accessories to travellers came
within the exemption. On appeal, it was held, that the exemption
does not authorize the sale to travellers of any supplies and accessories
other than those connected -with motors, cycles, and aircraft.

Appeal allowed and case remitted.

leqal decisions

684

MEDICAL ANNUAL

London County Council v. Wclfovd's Survey Dairies Limited
{King's Bench Division),

Shops Act, 1912, 55. ^1 (i), (f)), TO (i), (2), and Second Schedule —
Weekly half-holiday — Exemption — Perishable articles and confectionery
— Butter and rum honey.

Magistrate decided that butter and nun honey were, under the
Schedule, a “ perishable article ” and ‘'confectionery” respectively;
but, on appeal, it was held^ that butter was a “ perishable ” article
within the meaning of tlie Schedule, but that rum honey was not

confectionery ” within the meaning of the Schedule.

Appeal allowed and case remitted.

13. Smoke.

Armitagc Limited, v. Nicholson {King's Bench Division).

Bradford Corporation Act, 1910, ,«?. 53 — Nuisance from the emission
of smoke — Negligent stoking — Liability of occupiers.

The occupiers of a dye-house were convicted for creating a nuisance
by the emission of smoke from furnaces, constructed on the principle
of consuming, and so as to consume or burn, the smoke arising from
such furnaces. Against this conviction an appeal was lodged, on the
ground that the nuisance was due to negligent stoking, and that the
occupiers of the dye-house were not liable for such negligent stoking.
It was held, on appeal, that the conviction must bo affirmed, as the
appellants were, under the Act, criminally responsible for the negligence
of their stokers. Appeal dismissed.

i.|. Unsound Food.

Cointat v. Myham & Son {King's Bench Division),

Piihlio Health {London) Act, 1891, v^. 47 — Sale of Goods Act, 1893,
s. 51 (2) — Damages for breach of implied ’warranty under contract —
Meat unfit for hwman food — Damages to include fine, costs, and loss of
business.

A retail bti teller was convicted ami fined (with costs) for exposing
a tuberculous pig, unfit for human food, under s. .j,; of the Lhiblic
Health (London) Act, 1891. Me entered an action against the vendor,
from whom he purcliased the pig, claiming damages, including fine,
costs, and loss of business, and the High Court held, tliat neither
the damages arising out of the conviction, nor the damages caused
by loss of business, were too remote — the special loss being in fact
actually in contemplation, or such as might be taken to bo in the
contemplation of the vendor at the time of making the contract.

fudgment for the plaintiff

15. Unfenced Land.

Upjolm v. Willesden Urban District Council {King's Bench Division).

Willesden Urban District Council Act, 1903, s. 32 — Unfenced land
— Power of Urban Authority.

Held, that, if a piece of land was not provided with a fence which
was reasonably effective for the purpose of preventing persons from
going on the land, it was “unfenced” within the meaning of the
section, and that the question of its user was a matter for the Urban
Authority, and not for the Justices. Appeal allowed.

PUBLIC HEALTH

685

INDUSTRIAL DISEASES

16. Veterinary Surgeons.

Royal College of Veterinary Surgeons v. Kennard
{King’s Bench Division).

Veterinary Surgeons Act, 1881, s. 17 (i) — Unqualified persons —
Canine surgeries.

The Royal College of Veterinary Surgeons laid an information
against an unqualified veterinary surgeon for using the title of canine
surgery/’ but the Justices dismissed the information with costs. On
appeal, it was held, that the words canine surgery ” were a description
of a place and not of a person, and that, therefore, no offence had
been committed against the Veterinary Surgeons Act, 1881.

Appeal dismissed.

17. Water Supply.

Metropolitan Water Board v. Avery {Court of Appeal).

Metropolitan Wafer Board {Charges) Act, 1907, s. 25 — Supply of
water for lunch catering is a domestic supply.

At a public house, lunches were served, and the Water Board claimed
extra payment for water in consequence, more water being required
than in an ordinary iDublic house. The matter came before the King’s
Bench Division on appeal from the County Court decision that the
water supply for lunch purposes was not a domestic supply ; and the
King’s Bench Division allowed the appeal, holding that the water
used in the catering business was supplied for domestic purposes,
the test being the user to which the water was put. A further appeal
was made to the Appeal Court, and the decision of the Divisional Court
was upheld. Appeal dismissed.

III. INDUSTRIAL DISEASES AND TOXICOLOGY.

Diachylon and Plumbism.

Miscarriages amongst wliite-lead workers are common. Female
labour should, therefore, be abolished in the dangerous processes of
white-lead manufacture. Another source of plumbism amongst
women is the use of diachylon-plaster pills for the purpose of procuring
abortion — at least amongst women in the Pottery Districts. Much
acute and protracted illness, and even death, may result from the
practice. Lead is a powerful ccbolic, probably acting upon the
unstriped muscle-fibres of the uterus. The sale of diachylon should
be prohibited.

Miners’ Nystagmus.

Miners’ nystagmus causes a loss to the State of about ^100,000
per annum, and great suffering to the miners afliicted. The disease
was iDlaced upon the Schedule of the Workmen’s Compensation (1906)
Act in 1907. Defective illumination of mines is to blame, though,
doubtless, errors of refraction, want of muscle balance (weakness of
internal rectus), and a neuropathic diathesis may contribute also.
Defective illumination of mines is the chief cause, and not, as was
formerly held the, cramped position in which some miners have to
work and the consequent eye-strain. Mines lighted by safety lamps
are specially bad, whilst lines lighted by candles are, more or less,
exempt from the disease amongst the workers. It is only in coal

INDUSTRIAL DISEASES 586 MEDICAL ANNUAL

mines that tlie disease occurs, mctalli lerous mines, i‘or instance, being
exempt, altliough the hours of work are as long and the cramped
positions as common as in llic former, 'fhe real nystagmus is the
oscillation of the eyes, but other concomitant symptoms are twitcliing
of eyelids, nodding of head, tremor of hands, etc. The oscillation of
the "eyes may be rotatory in one, vertical i i the other, or vertical in
one and horizontal in the other, whilst the most general neurotic
symptoms, outside the ii^rstagmus, may be grouped together as a
complex neurosis, generally ending finally in the nystagmus.

Occupational Brass-poisoning : Brass-founders’ Ague.

Brass is an allo^^ composed of copper and zinc. Fine brass or red
brass contains two parts of copper and one part of zinc, but many
other qualities exist, containing dilferent projiortions of the two metals.

Bronze is an alloy consisting of copper ami tin, generally nine parts
of copper to one part of tin, but, in the trade, line brass or red brass
is often called bronze. Other metals ate often incorporated, e.g.,
lead, aluininium, phosphorus, antimony, and nickel. Brass~])oisoning
is due to the inhalation of fumes arising from molten brass within
the brass foundry. “ Brass itch'* is known amongst brass-polishers,
and is due to the slight irritation of brass dust, combined with habits
of unclcanliness. There is no peculiar poisoning due to trauma from
brass or other industrial exposure to brass dust, as amongst polishers ;
but a greenish discoloration of the skin, hair, gums, etc., may occur,
due to the copper constituent entirely.

“ Brass-founders* ague *' is an acute malaria-like syndrome of chill,
fever sometimes, and sweat, due to inhalation of vapour or fumes
arising from molten brass or from the fumes of pure zinc alone. Pros-
tration follows, ending in sleep. The attack lasts five to twenty
hours, with small and rapid pulse (120 to 130 per minute). Respiratory
diseases (bronchitis and plithisis) are common, as are also chronic
dyspepsia, biliary trouble, constipation, Inemorrhoids, pyorrhaxi
alvcolavis, anienua, and emaciation. It may be due to acute ('.opper-
poisoning, zinc-intoxication, or other metallic or other poisoning ihie
to the contaminating metals ami impurities encountered in tlie process
of manufacturing brass. 'Fhe pvevenlive nicdaurcs are: (i) Proper
liygienic surroundings in foundries and smelters ; (2) Regulation of

workmen’s habits ; (3) Hoods and slacks to fnrnaci^s and furnace

areas ; and (4) Ventilation generally.

Phthisis in Derbyshire Quarrucs.

Derbyshire, as a connt^'-, has three dilYerent forms of quarrying,
and a large agricultural area, and the incidence of pulmonary tubercu-
losis (phthisis) on these various districts is interesting, as shown by
a Report just published (1913). The highest rate is in the millslone-
grit quarries, the grit containing 96 per cent of silica, wJiich may be in
very tine subdivision as dust. This silica dust is insoluble, and
remains fixed ir the mucous membiane of the bronchial tubes, leading
to irritation, thickening, and abrasion, the last-mentioned forming an
entrance for the tubercle bacillus. The death-rate amongst the mill-
stone-grit miners is ten times as great as that amongst the limestone-
miners, and twenty times as great as that amongst the agricultural
dwellers in the same area. It is probable that the so-called “ grinders*

INDUSTRIAL DISEASES

PUBLIC HEALTH 687

rot ” in large towns is due to the particles of gritstone, rather than of
the metal which is being ground.

The death-rate from phthisis is higher amongst linie-quarrymen
than amongst coal-miners, the particles of carbon in the latter case
acting as disinfectants. The preventive measures that suggest them-
selves, such as the wearing of respirators, bathing and washing, etc.
are difficult to enforce locally, long-established custom being hard
to break down.

Special Illness amongst Weavers of Cotton Cloth.

A Report has been issued during 1913 by the Home Office, dealing
with an unusual form and amount of illness amongst weavers of
cotton cloth at Colne and Burnley. The symptoms were feeling of
tightness across the chest, rapid breathing, persistent irritating cough,
expectoration of a thick yellow or yellowish-green sputum, sweetish
taste in the mouth, etc. — ending in asthma symptoms, epistaxis (at
times), and insomnia; with general malaise, aching limbs and back,
severe frontal headache, and fever. Loss of weight ensues. The
cause given in the Report is mildew (unusual form) developing on
the cotton threads following the process technically known as “ taping ”
or " tape-sizing " with a preparation principally composed of flour
(derived from wheat, sago, or potatoes), tallow, china, clay, and
water. As a preventive, formaldehyde as an antiseptic is recom-
mended in place of the usual antiseptic employed in other processes
of the trade, viz., chlorides, which are specially forbidden to be used
by the dyers who purchase the particular goods under investigation.
The illness is fortunately very rare.

Workers and Industrial Anthrax Infection.

During 1913 a Committee was appointed by the Home Secre-
tary to inquire into the dangers from infection b}^ anthrax in
the processes of sorting, willeying, washing, combing and carding
wool, goats’ hair, and camels’ hair, and in the processes incidental
thereto ; and to consider and report whether any, and, if so, what,
amendments are desirable in the Regulations for these processes made
under s. 79 of the Factories and Workshops Act, lyoi. The Right
Hon. Sir Thomas P. Whittaker, M.P., is Chairman, and Mr. G. E.
Puckering (one of H.M. Inspectors of Factories), Secretary to the
Committee. The address of the Secretary is 72, Bridge Street,
Manchester.

Workers and ]Manganp:se Toxicosis.

Prof, von Jaksch, of Prague University, has placed on record,
during 1913, the symptoms due to manganese poisoning or toxicosis,
which is met with amongst workers in potassium permanganate, in
manganese mills, and in mines containing ores rich in manganous acid.
The symptoms are : convulsive laughter, weeping, and mental altera-
tions, followed b}’- retropulsion and what may be called pseudo-
Romberg symptoms, spastic gait, increased tendon reflexes, increased
salivation, mask-like expression of face, and monotonous voice.
Prognosis as to life is good, as to recovery bad ; and treatment
consists of cold-water cures, physical exercises, use of walking-chair
and electricity. Experiments with dogs breathing in manganese
dust proved negative.

THE EDITOR’S TABLE.

Samples and particulars for this section should be sent to The Editor ^ ** Medical
Annual*^ Offices, Stonebridge, Bristol, before November 15th, It is much to
the interest of manufacturers to observe this rule,

NEW PHARMACEUTICAL PRODUCTS & DIETETIC ARTICLES.

We are always ready, when a sufficient quantity is sent to us early
in the year, to arrange for them to be tested in hospital practice and
reported upon; under other circumstances our knowledge is necessarily
more limited; but frequently the simple information as to where a
particular preparation can be obtained is all the practitioner requires.

NEW MEDICAL INSTRUMENTS AND APPLIANCES.

We give Inventors and Manufacturers the opportunity of bringing
their work before our readers entirely free of cost to themselves, and
subject only to the following simple conditions : —

(1) Each article sent for notice must have the novelty or improvement
claimed for it clearly stated upon a separate sheet or sheets of paper. This
should have attached to it a copy of any illustration {which must be small)
for which insei'tion is desired, and also bear the name of the firm.

The attention of Firms who send a large number of articles for
hotice is particularly directed to the above condition, as each article has
to be sorted into its proper department before it can be considered.

(2) Medical Inventors should merely describe the instrument, or
appliance, and avoid giving technique of operations.

The Editor is not able to accept reference to circulars, catalogues, or
literature as a compliance with these conditions.

We are anxious to express no opinion except as a result of practical
knowledge, and it is owing to this fact that a notice in the MEDICAL
Annual has come to be valued.

editor's table

689

APPLIANCES

MEDICAL AND SURGICAL APPLIANXKS.

Aseptic Instruments.—Cousiderable attention has been given during tlie
past year to the never and better method of keeping surgical instruments not
only aseptic, but ahvays ready for immediate use. The system of sterilizing
by boiling is not only tedious, but damaging to the instruments. Tentative

efforts were made by keeping instruments in alcoliol, but it is obvious that
the solution used should be non-evaporating and also a reliable antiseptic.
With the discovery that an aqueous solution of Brytstele, which is a more

powerful antiseptic

P'ig, 84.

than carbolic acid,
would not onl y prevent
instrunients rusting,
but preserve the lustre
of the steel indetinite-
ly, the way has been
made easy, and the
surgical instrument
manufacturers have
not been slow to afford
us the means of keep-
ing our instruments in
this way.

For a set of in.stru-
menls, such as would
be carried in the ordin-
ary ])Qcket case, we
have the Holbovn
Aseptic Pocket Case
[Pig. 83), designed l>y
Mr. H. Simmons, of
B o u r n e m o u t h, and
made by the Holborn
Surgical Instrument
Co. Ltd. This contains
a pair of scissors, two
jiairs of artery forceps,
a double pocket knife,
probe, dressing forceps,
and metal box with
needles and sutures,
and costs 35/-.

Another appliance of this kind is Landon's Surgical Case, produced by
the Medical Supply Association, 167-173, Gray's Inn Road, W.C. It holds
2 scalpels, 6 pairs of artery forceps or scissors, and spring forceps, and costs
30/-. This, as will be seen from Fig, 84, is more suitable for the sui'gical

APPLIANCES

690

MEDICAL ANNUAL

bag. 'J'lie same iirni also supply a ^hss tube with wire rack for holding
a single scalpel immersed in Brytslclc solution, for which they arc the
agents.

Messrs. Philip Harris & Co., of Birmingham, also have a Scalpel Cavricy
{P'ii- S5). This is an ingenious method of carrying a scalpel so that it can

nHluiP HAHRis tiCi:; uu

Fig. 85 .

be immersed in a test-tube and have its point protected, or any number can
be immersed in a wide-moiithcd bottle of suitable siijc. Price i /-.

The same firm have produced the most perfect Pockel Surgical Case {Pig.
86) for instruments immersed in solution that has at present been brought
to our notice. It is simple and compact, and is hermetically sealed by a screw
passing through its whole length and which fixes the lid. The dimensions
V of the case are bj by by ij inches. It

/ V contains a rack by which all the instruments

I it/ if lifted out en bloc, and it will be seen

1 JYft that they are sufficient to meet any ordinary

emergency. It contains 1 finger knife, 1 scalpel,
I pair Spencer Wells’ artery forceps, 1 spi*ing
dressing forceps, i pair scissors, i Abbey’s
needleholder, i perforated needle box contain-
ing 3 assorted spring-eyed suture needles, i
bottle ligature silk in alcohol, with metal
screw cap, 1 sharp hook, i double .sharp
Volkmann’s spoon, i probe, i director with
scoop, I record hypodermic syringe and 2
needles.

To meet the requirements of major operations, Mr. Sampson
Handley has designed a larger Instrument Case, which is here illustrated
{Fig, 87). It is 9 1 by 5i by 3j- inches. It can, of course, be made in larger
dimensions if desired. This case is adapted for boiling over a spirit lamp
if required. It is made by Messrs. Mayer & Meltzer, 71, Great Portland
Street, W.

editor’s table

APPLIANCES

Mr. T. North has also designed an Instninmit Sievilizev more suited
for major operations, which can be used either for sterilizing over a gas

fire or simply carrying the instru-
nients immersed^^ in solution. We

Bacteriological Benclu — The '' Hystos*'” Bench ^ i

90) has been specially designed for the use of general I?' \|||« yHI
practitioners and others who require an inexpensive ||;

and portable bench. It 'is so arranged that the I' 'j H

f necessary con- iji' ,1 B

'i I'i 'liH Biiliil fitted for Pasteur filters, etc.

1 1 I ■ ' 111 ■ I strongly made of pitch pine,

' ' l 11^^ with mahogany or teak top, by Rey-

, tie 1 ^ J nolds & Branson Ltd., Leeds. Price

Bandage Winder. — A new form
of this appliance {Fig. 91) has been
introduced which automatically
winds the bandage after the handle
has been turned a few times. It
thus leaves both hands free to
manipulate the bandage. It is
much more rapid in its action than
the ordinary winder. It costs 21 /-,
from Messrs. Philip Harris & Co.
Ltd., Birmingham.

Bandages. — The advantages of
the bandages illustrated below {Fig.
92) are that they are easily fixed
neatly and securely in position by
means of the adhesive plaster at
the end, and no safety pins or

APPLIANCES

MKIJJCAL ANNUAL

tying are required. Tliey arc supplied in warkuis .sizes lor llie finger, arm,
or foot, at very reasona])lc prices, by the Ht)]liorn Surgical liLstrumcnt Co.,
2b, Thavics inn, fi.C.

/flOHESIVr

Cabinet (Combination).— 03 shows a niost convenient arrangement
for ho.spital ward or surgery, as it combines in one appliance most ordinary
requirements — a cabinet for instruments, dressing tal)le, S boxes of lint,

wool, gauze, bandage, etc., .swing bowl and
shelf undernesith and bin feu'

soiled dressings. The whole is mounted on

I i ill ! rubber-tyred casiers, the total height

|[|llil|ilfc^^^ jHij being 63 inches. Supplied at /j6 6.s. by the

I i ~ Pi'l Surgical Manufacturing Co., 85, Mortimer

feSiwE?'! ‘ *****

-iih ,, ^

•jwSv I

^ /il Cabinet for Ledger Cards. - In ronm'clion
; r I with Messrs. Reynolds A: JJranson’s system

' 1, cards instead of ledgers, they Hii])ply

cabinets 94) for filing the leilgcM* cards,
which permit of quick and easy referentx*.
These can be fitted with alphabetical index
cards of various coinputations, 23’s, 5o\s, or
loo’s, also nuniei'ically, monthly and days
of w^eek. They arc .strongly made in
mahogany or oak, and have three movable aluminium partitions to keep
the cards upright. Price 15/-- We think this method will prove very
convenient. We have used a similar system instead of a case-book for
many years, and find it far better, as notes and correspondence can be filed
with the cards.

Catheter (Ureteric, Silk Web). — ^This is graduated in hall'-inchcs, alternately
transparent and opaque to the a'-rays, half-inch divisions, as designed for
Mr. Thomson Walker. Bougies are also made with silver-woven sjnral
covered with red clastic gum, opaque to the .v-rays, graduated to show
each half-inch. Both are also graduated specially to indicate each length

APPLIANCES

editor’s table

693

of 6 inches {Fig. 95). Messrs. Allen & Hanburys Ltd., j8, Wigmore
Street, W.

Chair, The “Grevillite” Folding. — This is
a marvellous piece of construction — the pro-
duction of a comfortable arm-chair with
velvet cushions, a very efficient leg-rest, so
that it will pack fiat into a space 4 inches
deep and yet be quite rigid and durable in
use, has required much mechanical skill.

Fiq . 95.

{Fig. 96). It is comfortable to
sit in, and has an attachment
which can be used either as a
side-table or book-rest. The leg-
rest packs awny under the seat
when not in use. Considering
that the chair, upholstered in
velvet, only costs 28 /6, and in
Fig. g6. striped canvas 15/6, and the leg-

rest and extra table another 6 /^
or 7/-, we think it should have a very large sale. We recommend it with
great confidence. Supplied by the Medical Supply Association, Gray’s Inn
Road, W.C.

Clamps. — The Intestinal Crushing Clamp here illustrated {Fig. 97) is one
which has been especially made for Mr. W. Ernest Miles, F.R.C.S., by the
Holborn Surgical Instrument Co., for use during the radical abdomino-

perineal operation for cancer of the rectum. The proximal half of the blade
is nearly an inch in breadth, in order that the crushed part of the pelvic colon
shall be sufficiently wide to permit of easy division between the ligatures.
The distal portion of the blade is much narrower, as it is only necessary to
crush the mesocolon, for hsemo- '
static purposes, along the line
of division. The advantage of
using this clamp is that it
greatly minimizes the risk of
infection when the pelvic colon
is divided.

Vaginal Clamp . — The accom-
panying illustration {Fig. 98)
shows a clamp for the vagina in cases of Wertheim's hysterectomy, designed
by Mr. J. Basil Hall, F.R.C.S. It is applied as follows. When the uterus

APPLIANCES

694

MEDICAL ANNUAL

is isolated from all its attachments, and the vagina is freely exposed, the
jaws of the clamp arc opened and passed over the Cundus uteri. The uterus
is then slipped through the fenestration of one of the jaws (preferably the
anterior), and the clamp is pushed down until tlie transverse limbs of the
jaws lie across the upper end of the vagina, when the clamp is closed. All
septic discharge is thereby shut off from the operation field, and at the same
time the instrument can be used as an efficient tractor, and
any slipping is impossible. The width of the jaws at the
widest point is 3 inches, wliich allows plenij' of room for
manipulations in the pelvis. The instrument can be used
for any ense except
one in which a large
h b r o i d co-cxists
with malignant dis-
ease, when the fib-
roid must first be
enucleated. Made
by Down Bros.

Ltd.

Fig. 99 illustrates the latest pattern of the Clamps^ made for Kochcr,
of Berne. The blunt knobs prevent slipping. There are three sizes
curved as illustrated, and two sizes .straight. The Holborn Surgical
Instrument Co.

Clip (Wire). — These clip.s {Fig. 100) are
very strongly made, and are useful for
keeping artery forceps, etc., together during
sterilization. They cost 7 /6 per dozen, and
are made by the Holborn Surgical Instru-
ment Co., Ltd.

Curette Sharpener. — This is made of Arkan-
sas stone in the form of a pencil mounted in
nickel-plated revei'sing case. It is suitable
for sharpening post-nasal curettes and other similar instruments with inner
cutting surfaces. It may be also used like an ordinary “ steel for putting
an edge on a .scalpel. It is quite a useful addition to the surgical case,
and is supplied by the Medical Supply Association, Gray's Inn Road, W.C,

Douche Tube (Vaginal) .—This is a
vaginal douche tube with rubber
shield. Very hot injections may be
used without scalding. The rubber-
covered terminal forms a plug to the
vagina, so that the hot water is
retained in longer contact with the
passage, and then flows back through
the outlet without escaping at the
sides of the nozzle. It is very practic-
able and novel, and may be obtained
from the Medical Supply Association.

Dressing Boxes (Glass). — The new
'' Grevillite " glass dressing box has
an improved glass lid {Fig. loi). The
lid is fitted with a polished glass knob
united by a nickel-plated metal union.

In case of breakage, new lids can be
replaced at a reasonable cost, and any
size supplied to order, as it is only
nece.ssary to cut the plate gla.ss to fit the box and refit the glass knob. We
find these boxes excellent for storing surgical instruments in antiseptic

Fig, in I.

editor’s table 695 APPLIANCES

solution. They only need for this purpose a tray of perforated zinc, for
lifting-out purposes. The Medical Supply Association.

Electrophone (The « Groos.*’)— This claims to be more perfect than
shiiilar instruments for aiding deafness, because it bears fine adjustment to
meet varied conditions. It is the absence of this power in the earlier instru-
ments which caused their failure in so many cases. It is well worthy of a
trial, and we understand that the makers will permit this before purchase.
The price complete is £2 2s, from the Medical Supply Association.

Ether Apparatus. — The principle of the intratracheal administration of
ether is now well known. Warm, moist, and etherized air is supplied to the
patient at the bifurcation of the trachea by means of a catheter passed through
the glottis. The air is under pressure, and as the catheter is only half the
size of the glottis, the excess of air escapes easily between the catheter and
the glottis. It remains, however, under sufficient pressure to expand the
lungs, and being constantly renewed, suffices for respiration. Though
primarily designed for the performance of surgical operations on the thorax,
it possesses further advantages in general surgery, (i) By its means thoracic
surgery is rendered possible without resorting to the cumbersome and costly

Ftg . 102 .

positive and negative cabinets. (2) In mouth, nose, and throat operations
there is no danger of the inspiration of blood, mucus, or pus. (3) In goitre
operations air is supplied below the tracheal obstruction. (4) In head and
neck operations the anaesthetist is well out of the way of the surgeon. (5) It
renders easy, from the slight respiratory movements, operations on the
upper part of the abdomen ; and (6) It is a most efficient artificial respiratory
apparatus. It consists of two parts : one for the production of the current
of air, which is obtained by an electric motor or a foot-bellows ; the other,
the ether apparatus {Fig, 102), which warms, moistens, and etherises the
current of air. It is designed by Mr. R. E. Kelly, F.R.C.S., of Liverpool,
Down Bros. Ltd., St. Thomas’s Street, S.E.

The ether apparatus illustrated on next page (^2^.103) has been devised by
Mr. G. E. Cask and Mr. H. E. G. Boyle for the intratracheal insufflation of
ether. Air is driven from the bellows a, through hot water in the bottle c
(the tap B is for air, and Bi is a reserve tap for oxygen if necessary). The
air then passes through e, over the surface of the ether in the smaller bottle,
and so on to the gum-elastic catheter. When it is desirable to give air
without ether, e e are turned off and g is turned on. By regulating these
taps it is quite easy to have either the whole or part of the air laden with

APPLIANCES

696

MKinCAL ANNUAL

ether vapour, '.riic luaiioineter i) ivj^isters the pressure undt'r which the air
is driven into the trachea. The apparatus and tlu* method of Jiuiintaining

105.

aniesthesia are mainly intended for intrathoracic op>eratir>ns. IMayer &
l\IcUzor, 71, Great Portland Street, W.

Ether Can. — This can, devised l)y JJ)r. \V. J, iMcCanlic,
of Birmingham, i.s made of thin metal, which quickly
takes up heat from the hand; it is inexpensive Jind un-
breakable. It has no neck, and therefore there is no
waste of neck space, which is a drawback to glass bottles.
The nozzle is simple in foi*m and covered with two
screw-caps. Being ether-tight, tlie can may be carried in
any position in the surgeon’s hag. Any form of dro])por
can be easily fitted. It hold.s xi oz. and costs 3/0
3 0i|). Mayer tS: Meltzer.

Fin. ru.|.

Ether Inhaler. — In this inhaler the glass jar is half fillctl with ether, and is
connected by the rubber tube to the two-way valves and face-ixiece {Ft^> 105)
The tube b is then adjusted so that its lower end just touches the surface of
the ether, and the extra air-inlet F is opened wide. The face-piece is now
adjusted, and the patient directed to breathe quietly. While the extra
air-inlet F is open no air should pass through the ether receiver, but as the
sleeve E is slowly and steadily revolved to gradually close the extra air-
inlet F, the patient begins to inhale through the ether receiver. The ckxsing
of the inlet f should be completed in abotit four minutes, and the tube B
should then be gradually immersed to the depth of about one inch, the whole

editor’s table

697

APPLIANCES

induction period taking about eight minutes. When the stage of surgical
anaesthesia has been reached, the tube b may be gradually raised until the
depth necessary to maintain anaesthesia has been determined. Suggested by
Mr. L. T. Rutherford, of Exeter, and made b5" Down Bros. Ltd,

Ether Mask. — This inhaler

Fig . io6*

{Fig. 106) is of the Schimmelbuscli pattern,
with a raised inner wall. It was de\'ised by
Dr. L. Ernest Acomb, of Newport (Mon.).
It obviates any danger of ether being
drojjped upon the face of the patient ; and,
as the respirator}^ space is to a certain
extent limited, saturation with ether can
be more readily obtained. Thus anaesthesia
can be more rapidly produced and more
easily controlled. JMayer & Meltzer.

Eyes (Artificial). — It is claimed for the “ Eukoric ” artificial eye {Fig. 107)
that when in shadow the outline of the pupil becomes indistinct and the pupil
appears enlarged, but in bright light the pupil is small and the outline distinct.
Supplied by Messrs. Mayer & Meltzer, who have also
produced an artificial eye extractor, for removing the
eye without injury to the socket.

Eye Douche. — This is an excellent arrangement
for giving continuous irrigation to the eye. An eye-
cap. furnished with an inlet for the supply of the
irrigating fluid, and an outlet to which an india-
rubber tube is attached for carrying off the fluid, is
supplied in conjunction wdth a graduated tube for
holding the solution. By this means the eye can be
irrigated with the indicated fluid more efficiently than with any other appli-
ance that has come under our notice, and we can confidently recommend
it. The cost is only 3/--. Ferris Sc Co. Ltd., Bristol.

Eye Instruments. — Messrs. R. Sumner & Co., Lord Street, Livei-pool,
send us a small set of eye instruments {Fig. 108), arranged so as to be carried
in an ordinary pocket case. It consists of a scoop, gouge, spud, spear-
pointed needle, and a magnet, all of which are carried in the handle, and

Fig . 107,

Fig . 108.

can be fixed at the end when required for use. They are found to be
very useful lor practitioners in manufacturing, iron, or colliery districts,
where they are frequently called upon to remove foreign bodies from the
eye. Price 12/6.

Forceps. — Hertzka's Straight Suturing Forceps is as ingenious as it is
convenient, enabling wounds to be sutured without assistance. The principle
is to combine two forceps in the one instrument, as shown in the illustration
{Fig. 109). First one side of the wound is grasped with two of the blades,
then the other side by the remaining blade, and the opposite sides are there-
fore brought perfectly together and can be easily stitched. This does away
with two forceps, and is an e.xceedingly simple procedure. We do not think
any surgeon who has once seen these forceps would be without them.
Price 8 /6.

APPLIANCES

69S

MEDICAL ANNUAL

Hertzka's Cuvucci Sut living Fovceps acts in a similar manner. This instru-
ment is used to close largo open wounds in order to draw the edges
togetlier and allow easy tying of the silk ligatures. Before use both slides

are opened. The forceps are
taken into the right hand in
such a way that the thumb rests
as usual on the slide. The slide
nearest to the wound edge is
closed by the thumb. The pres-
sure of the finger is moderated,
and the other two blades open,
and are used to grip the other
edge of wound,, whereupon the
peculiar slide is closed by means
of the middle finger. Price 12/6.

We also illustrate Hevtzka.s
Forceps for clamping Michel's
Sutures {Fig. 110). This forceps
is fitted with two finger-rests
for opening it to pick up the
sutures, which are then ready
for use.

Another very useful forceps is
Hertzka's Suture Threading For-
ceps (Fig. Ill) for threading
.split-eyed needles. All four
instruments come from the
Medical Supply Association,
167-173, Gray’s Inn Road, W.C.

Fracture Instrument.— Mr. G.
H. Colt, F.R.C.S., has designed
the instrument shown in Fig. 1 12
to overcome the difficulty some-
times experienced in reducing
the fragment.s before applying a
Lane’s plate in cases of fracture
of the long bones. Thi.s is especially noticeable in old-standing cases of frac-
ture of the middle of the shaft of the femur. Much of the force used is
applied through the knee-joint, and may caitse synovitis. The maintenance
of extension is excessively tiring to the assistants, ’i'hc iustrinnent is usocl as
follows ; Extension is carried out in the usual manner, without using undue
force, and then the fragments are seizetl with two Lant^'s bone-holding forccp.s
applied parallel to each other and as near together a.s po.ssible. The slot-
pieces on the screw are then adjusted equally from the middle to fit the
distance between the forceps, and the instrument is lower(‘d over them so
that the slots engage them and the ha.sps are closed up. The handles of the
forceps are held one in each hand by an assistant, and the operator turns
the screw until extension has been pi*oduced. The plate is then applied.
If necessary, coaptation may be maintained by applying a third bone-
holding forceps to the fragments, and in this case the instrument may be
removed while the plate is applied. Down Bros. Ltd., St. Thomas’s
Street, S.E.

Fumigator {^‘Gonin **). — This clever device has been sent to us by M.
Bresillon & Co., Gamage Buildings, Holborn, E.C., who are the British
agents for the makers, a Parisian firm. It consists of a small canister of
“ Fluoforinol Gonin,” a white powder combining sodium fiuoride with
paraformaldehyde ; the lid of the canister is perforated and the perforation
sealed with wax, the whole canister being enclosed in a thick envelope of

EDITOR S TABLE

699

APPLIANCES

paste-board, -which burns like touch paper. For disinfection of a room,
the usual sealing-up of windows and doors is carried out ; the paste-board
covering is ignited, this melts the wax and opens the hole in the lid, at the
same time heating the powder contained within the canister and \'aporizing

the paraformaldehyde. These contrivances are sold in boxes containing three
each, of different sizes ; and for those who cling to the belief that it is possible
to disinfect a room by any form of germicidal vapour, they may be recom-
mended as economizing "trouble and avoiding risk. The outer covering
needs a little coaxing to make it burn ; the makers warn against the use of
kerosene, which makes it burn too fast. Full directions are supplied.

Geyser for Surgery (Hot Water).— (Ffg. 113) —

Intended to be fixed over a hand basin, to an
ordinary cold-water supply, and heated by gas,
so that hot water is available at all times.

The cold water enters at the bottom into a
narro%v cylindrical-shaped container, provided
with gills, which radiates the heat from the
burner to the walls of the container, thus get-
ting the maximum of temperature gi\'cn off
by the flame. The water can by this means
be raised to a temperature of about 160' F.,
but the output depends upon the temperature
at which the water is required. It is entirely
constructed of copper, the water- and gas-Avays
being heavily tinned, and the outer casing
nickel-plated, so that it quite harmonizes witli
the general appearance of surgical appliances.

It is a very convenient apparatus, price ;f3 los.
net. R. Sumner & Co., Lord Street, Liverpool.

Grate (Adjustable). — This appliance can be
fixed to an ordinary fire-grate, with the bars
removed, with the result that the fire is
brought 5 inches further forward and the heat
better distributed in the room. When carefully
stoked it makes an economic fire, as well as a
more efficient source of heat, and it Avill be a valuable addition to those
fire-grates which appear to have been specially designed to allow all the

APPLIANCES

700

MKDICAL ANNLTAL

lieat to go up the chimney, 'riit* cost is small, lo/o to 12/b, according to
size, and they can be qiiicltly adjusted by Ihe purchaser (F?:g. n,^).
Adjustu.blc Clratc Ct)., \h)rk Koacl, lllord.

FiS’ ■04.

Haemacytometer (Hayem-SahU).-~-This is a
great improvement recently introduced by
E. Leitz, of rS, llloomslniry Stjuare, London,
in accordance with the suggestions of Pro-
fessor vSahli. Th(‘ JippanUus is extremely
simple in its manipulation, it supplies ^'ery
reliable readings, and abo\'e all does not
cause fatigue. With the aid of the tables
provided with the iipparatus, the number of
red or white corpuscles contained in a cubic
milUmctre. of blood can bo read oil at once.
The advantages pos.sesscd by this apparatus
are sufficiently pronounced to ensure its intro-
duction in lio.spitals, clinics, and also among
general prac-
tioners,

Hse mor-
rhoida! Belt.

-This simple
and inexpen-
sive bandage
{r ig. 1 1 5 )
s u p p 1 i e s a
long- Celt want
to patients
s u If c r i n g

from piles, fistula, and any diseases of the rectum. A serviceable belt is
provicled for pheing round the w^aist, at a cost of (Jiie shilling, and absorbent

pads are supplied for attaching to this al a. cost of 3/6 per
doz. The arrangement will prove inv'al liable in a. wide
number of cases. The Holborn Surgiciil Inslruinent Co.

editor’s table

701

APPLIANCES

scissors, also antrum, sphenoidal, ethmoidal, and tonsil punches, can be
attached. It is very powerful and efficient. Extension pieces are made,
so that it can be adapted for lar^mx and oesophagus. At least 50 blades
are made, of well-known patterns, to fit the handle, and they can be
rotated and fixed in four different positions, so that the instrument can be
turned to the right or left, up or down. The mechanical action is perfect,
and it gives clean cuts. Cost of handle, 17/6. Blades 15 /- upwards. E.
Sumner & Co., Liverpool.

Head Dressing (“ Tabloid ” Adjustable). — One of the first lessons which
the dresser has to learn in hospital is the difficulty of securing dressings
on the scalp, a problem which is likel}' to haunt him in after years. Messrs,
Burroughs Wellcome & Co. send out a head bandage in a small watch-pocket
parcel w’hich includes a safety pin, a cyanide gauze pad, and full illustrated
directions in several languages — a model of neat packing. The bandage
consists essentially of a cap, split at one side to make it easy to adjust, wdth
a tail long enough to pass round the forehead and fix the cap in position.
We applied it to the editorial head, and found it easy to put on and comfort-
able as well as secure to wear. A larger size includes a back-piece to cover
the nape of the neck, with tapes for securing it. As the makers point out,
it may be used not onlj^ for dressing injuries but also for covering in the
head during operations on the ear, eye, nose and throat, and also for the
ti'eatment of scalp infections of various kinds. The cap is washable.

Hypodermic Needles. — The Astra scamless-steel hypodermic needles arc
“ sprung-in ” needles without solder or screw. 7 'hcy are guaranteed not to
leak or break in normal use. They are put up in a neat tin box of one dozen,
price 3/6, by the IMcdical Supply Association, Gray’s Inn Road, W.C.

Hypodermic Syringes.— We illustrate here {Fig, 117) an all-glass syringe
which has the advantage that the barrel has facets on the exterior, which
prevent the instrument rolling -when laid down ; also that the piston is of

io?. 117.

coloured glass, which shows up the markings very distinctly on the flat
surface of the syringe. Price, in metal case with tube for carrying needles,
5/-. R. Sumner A Co., Lord Street, Liverpool.

Messrs. Burroughs Wellcome Co. arc resptmsible for an all-glass aseptic
syringe for administration of tuberculin, etc. {Fig. 118). It is particularly
designed for administration of substances which, like tuberculin, have to be
given in minute doses. The barrel and piston are elongated to about double
the length of the ordinary hypodermic syringe ; the former is clearly engraved
with numbered gradations of i to 10, between which are marked half grada-

Fig . n8.

tions, each equivalent to *05 c.c. By this means the I'equired dose can be
given with great accuracy. Both piston and nozzle are of deep blue glass,
so that the position of the former can be readily determined with considerable
precision. The syringe can be taken to pieces easily and boiled. Owing
to the clearness with which even -05 c.c. can be seen in the syringe, dilutions

APPLIANCES

702

MKDICAI. ANNUAL

can be conveniently ina,<U^ within the barrel by drawing up the necessary
quantity of nornuil saline solution after the tuberculin, h'lill directions
arc supplied with each syringe, which is complete and ready
I lor nse.

K The “ Ideal" hypodermic syringe {h'ig. J 19) is made of glass

If \\-ith nLctallic strength, the chief feature of which is the detach-
es® nozzle held in position by a metal screw rim. The rim

holds it absolutely ripd and air-tight, yet when this rim is un-
ri screwed the nozzle is readily loosened by pushing the piston

J|ri lunnc. The ]nstoii is constructed of a solid non-corrodiblc

metal, and hts the barrel with absolute accuracy, thus
preventing the Iluids from being forced behind it." With
■ I all-gla.ss syringes there is a danger of fracturing tlie
^ nozzle by contact with the piston ; witli the solid metal

nozzle this is obvioii.sl}^ impossible. Tlie solution is
instantly prepared by the insertion of the uncompressed

IB il rt |

A novelty in hypodern no syringes Ijl;,' /.Ql w I ' |jj|, j ’J

is one of all glass, in which the |I| v j|iM ' | r''|| j’ ji', I
piston rod forms a receptacle for ] r,j| 1 77?, || , |

the needles, as shown in our illus- > !j | || ZD's: I

tration (F?g. 120). It makes a very |j|[|ggg;^ ^ ' I ;i|! 15 *sj } ||

portable syringe.^ 'the ITolborn ||||||l : ||’''l| 10-^1 | |

We mention the syringe illus- || I iM , I !i|| tJ-

trated (F/,g. 121) because it is || || W , | ,||| (J

claimed to be the cheapest all-glass IllilW |! 1||l' ,i ||

syringe ever offered to tlu! medical |||iira
pndession, It holds 20 minims,

and has two needles, a holder, and i.,„,

aseptic metal case. It costs 1/9,

or 18/- per dozen, and is made by the Ilulburu Surgical instrument Co.

The most important de-
velopment in syringes is the
30 c.c. all-metal syringe
nxade by Chas. h\ Thackray,
of 6(3~7 o, Great George St.,
Leeds. It was designed for
surgeons who employ solu-
tions of quinine and urea
and novocaine in their oper-
ative work, as recommended
by Crile in his article on
'' The Anoci Association
Theory of Shockless Opera-
tion," published in the Lancet of July 5th, 1912. It is interesting to note
that Dr. Crile himself has found this syringe perfect for its purpose.
A special feature is the ingenious way of fixing the needles to the syringe
which, while allowing of their easy detachment, absolutely prevents the
needles from slipping, or allowing leakage. The needles themselves are

editor's table 703 APPLIANCES

deeply inserted into the needle mounts, which makes breakage of them an
impossibility under ordinary conditions. When filled with solution it is
perfectly balanced, and the finger grips, which are made to
revolve, provide a means of maintaining the syringe perfectly
steady in the hand, even when great pressure is required for
injection. It can be plunged into boiling water, for steriliza-
tion, without harm, a procedure not possible with metal and
glass syringes.

We have carefully tested this syringe, and find the
arrangement by which Schimmers needle can be adapted
most perfect. The adapters enable the needles to be inserted
either in the straight or right-angled position, and these
needles can be supplied of any length and of very fine
calibre. W’e regard it as the most perfect syringe we have
yet examined. We understand that smaller sizes arc in
preparation. The cost of the 30 c.c. syringe complete is
only 25/-.

Infusion Apparatus (Souttar’s). — This consists of a quart

Thermos ” flask, fitted, as shown in Fig. 122, with an
india-rubber rectal pipe and a Canny Ryall drop-regulator.

It has also a water-gauge and three-way tap. By this
method the temperature of the water can be maintained for
many hours, the fall of temperature being only 1° F. per
hour. It is very simple and efficient, costing £z 5s. Allen

Hanburys Ltd., 48, Wigmore Street, W.

Inhalers.

The Harris-Yeo Improved Inhaler. — Dr. Burney Yeo's inhaler,
which is universally used, is found not to admit enough air. This
is especially evident in those cases where rapid respirations, cough,
dyspnoea, and the accompanying cardiac embarrassments were
prominent features. These symptoms were usually much increased,
often dangerously so, by the obstruction which was offered to the
respirations by the closed inhaler. The illustration {Fig. 123)
shows A cut away and acting as a ventilator, which not only

brings about better results,
but is much more
comfortable to use.

The object of this inhaler, of course,
is not only to apply the inhalation
to the lungs and air-passages so
that there will be no obstruction
offered to the respirations, but^ also
to allow a free exit of the vitiated
expired air, and thus a free^ entry of
pure air on inspiration. The lid B
takes off to enable the patient to
remove it once or twice daily to be
cleaned. This cap also prevents the
inhalant trickling dowm'the side on to the patient’s face. Cost 12/- per
dozen. Philip Harris Co. Ltd., Birmingham.

Chloride of Ammonium Inhaler . — Under the name of the "Pocket
Kloram ’’ Mr. Frank A. Rogers, of 327, Oxford Street, W., has improved his

APPLIANCES

704

MEDICAL ANNUAL

original a])parattis so that it now represents the last word in such appliances.
A tube, shaped like a large cigar, is “ smoked,” with the saune freedom. The

vapour is obtained from two cartridges
placed in the tube, the capsules which the}-
contain being crushed at the moment of
doing so. There is
no acid to measure
nor bottles to keep
corked, merely a
tube and a supply
of cartridges {Fig,

124).

Nasal Inhaler . —

This holds itself
in position on the
nose (Fig. 125I just as docs a pair of pince-nez, in
such a way that inedicaments are placed upon
cotton- wool and held exactly below the nostrils,
so that the patient can conveniently inhale for
long periods. It is made in three sizes, for men,
women, and children. Price i '6 each. It is a
distinctly ingenious and practical invention. The
Medical Supply Association, Cray’s Inn Road,

W.C. ■ ■ ^-’ 5 -

Invalid Lifter. — M'c goA'c a number of illustration* showing iMr. Skclitingtoji’s

124.

method of lifting patients in bed, in our last issue,
his latest invention for lifting a
patient so that the bed-pan _ can
be used without the smallest fatigue
or inconvenience. The simplicity
of the mechanical arrangement
involved will be at once obvious,
and we think that every hospital
or nursing home should have one
or more of these appliances, which
solve a chronic difficulty in serious
cases. Mr. A. Skeffington, 49,

Ulundi Road, Blackheath, S.E,

Invalid Support. — Fig. 128 shows
an arrangement designed by Dr.

Hamilton Whiteford, of Plymouth,
for keeping a patient in the * ' Fowier
position.” It is used in conjunction
with an ordinary bed-rest, and the
mechanical details will be easily
understood from the illustration.

Alien & Hanburys Ltd.

Figs. 126, 127 illustrate

Fig . 12S.

editor's table

705

APPLIANCES

Irrigator. — A very simple and practical form of irrigator, and one easily
kept sterile {Fig. 129). It is made in three sizes,

35, 50 and 100 oz. If broken, a new glass with
cover can be had for 2 /6, 3 /-, and 5 /- respectively.

A complete 35-02. apparatus with metal-plated
cage costs 5 /6. The Holborn Surgical Instrument
Co. Ltd., 26, Thavies Inn, E.C,.

Irrigator Stand (Canny Ryall’s). — Complete with
three glass solution reservoirs, with tubing and
clips for controlling the flow {Fig. 130). It is also
fitted with brackets for holding glass box, glass
bowl, enamelled iron tray, and drip catcher, these
bi'ackets being placed at convenient positions on
the standard. An outfit of special double-channel
urethral irrigation pipes and a metal vaginal nozzle

Fis . 129 .

Fig . 130 .

plugging on to the metal stopcock is provided. Allen & Hanburys Ltd.,
4$, Wigmore Street, W.

Knife (Bruning’s Guarded). — ^This w-as originally invented by Professor
Pruning for ear and nose work, but it has been found very useful for a general
guarded knife, which a surgeon can carry about without any danger of

Fig . 131 .

injuring the point or the blade {Ftg. 131). It will answer very satisfactorily
for tenotomy, ear, or nose, in fact, any operation where a small knife is
required. Allen & Hanburys Ltd., 48, Wigmore Street, W.

Lamp (Head).' — An electric head lamp has been sent us by Messrs. Ferris
and Co. Ltd., of Bristol. This has a band for the forehead and is enclosed
in an aluminium case, which renders it very portable. It is most efi&cient
and only costs 21/-,

APPLIANCES

706

MEDICAL ANNUAL

Diagnostic Head Lamp , — The diagnostic head lamp which we illustrate
here {Fig. 132) is well made and remarkablj?' cheap (cost £1 as. 6d.). Such
lamps are very useful and reliable if
the practitioner takes care to provide.
himself with a few spare lamps and
an additional battery. Its great con-
venience is its portability. Philip /^ /

Harris & Co. Ltd., Birmingham. ^Bj

The convenience of these lamps WU
when on the visiting round makes them H[

0 desirable addition to our resources.

ilillfcfflwosis Ill'll AMP , '!

Laryngoscopic Apparatus. — This
apparatus {Fig. 133) is a modified
form of Killian’s, and is suggested
by Mr. W. G. Howarth, F.R.C.S.
The following are the advantages
claimed : (i) The opening A is twice
as wide, being 2 inch as against i
inch. The wider \'iew is especially
useful in operations in the deep
pharynx and upper aperture of the
lar3’nx ; (2) The counter-pressor B
runs on an arm and is adjustable ;
this has proved ol great advantage
in the presentation of the anterior
commissure ; {3) A swivel joint has
been inserted at C ; (4) Small modifi-
cations have been made in the size
and width of the spatula and in
other points. Down Bros. Ltd.

Leg-Cradle. — ^Mr. B. Richardson Billings
has designed a leg-cradle, modified from
the ordinary pattern, as the illustration
vdll show' {Fig. 134). The hoops are, on
one side, made concave in the lower
part of their ordinary convexity, this
hollow^ing-out allowdng the uninjured leg
to lie comfortably parallel alongside its
fellow, and not in a spiayed-out condition
as is the case with ordinary patterns.

editor’s table

707

APPLIANCES

The advantage is obvious, and we can commend the invention. Cost 8/6.
The Holborn Surgical Instrument Co.

Ligature Bottle. — A handy little glass bottle
with a ground-in lid and no shoulder. It is i
enclosed in a spiral metal case, which screws
down to any depth and firmly secures the
stopper. It is made in two sizes at 2/6 and
3/- each. This is both practical and orna-
mental, and will be found useful for many
purposes {Fipi. 135). The Holborn Surgical ^

Instrument Co.

Ligatures (Emergency),

— ^This is a neat case con-
taining a selection of liga-
tures in hermetically-sealed
tubes. The selection con-
sists of catgut, silkworm
gut, and horsehair, supplied
as the purchaser desires.
Ea,ch tube contains a
needle. They are excep-
tionally handy little cases
to carry in a surgeon’s
136 pocket, being always ready

^ for immediate use. The

case complete with six tubes {Fig. 136) costs 5/6, and refills 8d. per tube.
R. Sumner & Co. Ltd., Liverpool.

L- i' ^

Magnifier (Third Hand). — This ingenious apparatus consists of a magnifying-

glass attached to a universal joint,
which in turn is fixed to a spring
slip {Fig. 137). The latter can be
placed on the thumb, leaving both
hands free. The instrument will
be found' ino.st useful in removing
foreign bodies from the eye, etc.
Price, including leather case for
lens, 6 /-. Reynolds & Branson
Ltd., Leeds.

Massage Apparatus (The “ Peso ”).

— This is an ingenious appliance.
It consists of rollers, which are
pushed backwards and forwards
over the skin. This action revolves
a small dynamo, so that an electric
current is produced which is greater

Fis, 137 *

or less according to the rapidity of movement and whether the skin is dry
or damp. For practical use it requires a longer handle than the one
supplied. It costs 30/-. The Medical Supply Association, Gray’s Inn
Road, W.C.

APPLIANCES

70S

MEDICAL ANNUAL

Micrometer Eyepiece (Step). — In this micrometer the intervals are arranged
in groups of ten, each group being indicated in an unmistakable manner by
. a black echelon rising from the first to the tenth interval.
Ernst Lext2 arrangement possesses the great advantage that the

Wetzlar. divisions can always be seen distinctly, whether the objects

be light or comparatively dark. The intervals of the scale

[Fig. 138), instead of being or mm. wide, as is usually
the case in eyepiece micrometers, have a definite value of
o'o6 mm. The object of this departure is to obtain for each
objective and for a given tube length convenient, and in the
majority of cases integral, micrometer values, which greatly
facilitates the use of the instrument. The actual tube length
differs in most cases but little from the standard length.
Each step micrometer is supplied with a table of micrometer
constants and corresponding tube lengths computed for the
Huyghenian eyepiece No. II and each of the Leitz objectives.
E. Leitz, 18, Bloomsbury Square, W.C.

Microscope (Double Demonstrating Eyepiece).-— By mean.s
of an eyepiece which slides into the tube of the microscope
{Fig, 139), fitted with an arrangement of prisms, the image
formed by the objective can be viewed by two persons.
Apart from its function as a demonstrating eyepiece, it is
a useful adjunct in the instantaneous photography of living
bacteria illuminated wdth the dark-ground condenser. It
affords an excellent means of hitting off most ixropitions
moments for taking the photographs. The eyepiece can

J, I I I bo adapted to any ordinaiy microscope. It is

made by Mr. E. Leitz, 18 Bloomsbury Square,
W.C.

Microscopic Slide Tray. — ^The “Rysios*' microscopic slide tray {Fig. 140)
consists of three concentric troughs, accommodating respectively 7, ii, and

17 slides, 35 in all. Immediately
^ after being washed, the slides can

. >r v. \ be placed almost upright in the

trough for drying ; the water
which drains from them is got
r through holes pierced for

u purpose. There is thus no

\ y i^scd for blotting-paper. If the

labelled ends are placed upper-
L I ' most, any slide required can be

picked out in a moment. The
space within the circles may be
/.•jVr, 3^0. used either for the bottle of cedar

oil, or for the reception ot slides
after they have been examined. The tray is made of zinc and is easily kept

editor's table

APPLIANCES

clean. It takes up very little room, as it measui*es only lo inches in
diameter, and is easily carried about from place to place if required.
Reynolds & Branson, Leeds.

Micro-Telescope {“ Davon ’* Patent). — By this invention an ordinary
microscope can be transformed into a realty very wonderful telescope. The
principle of the image formed on the retina when looking at an object through
a pin-hole is the foundation upon which this remarkable invention has been
evolved. A good 6-inch telescope objective is inserted into a 6-inch tube,
the latter being provided with a carefully and correctly graduated series of
** stops ” down to the final one of about 2 mm. in diameter. As a result of
this the most perfect image of a distant object, free from all halation and
image lines, is brought to a focus in the plane of the microscope stage, and
in this condition will stand the tremendous magnifying power of the
microscope. In other words, the microscope as a w’hole forms the eyepiece
of the telescope. Distance does not affect it. A magnification of from 35
to 50 diameters can be obtained from 4 feet away to the planets. When
it is realized what this means, the varied uses to which it may be put
will be apparent. The habits of insects, birds, etc., can be studied
without disturbing them. Jupiter’s moons, Saturn’s rings, and the craters
of the moon have been seen under ordinary telescopic conditions with
wonderful distinctness. For medical purposes it forms a fine instrument
for examining the skin, for by placing the patient 5 or 6 feet away the
whole area under examination can be viewed by a slight movement of
the apparatus.

A second attachment of 4-inch focus is also made, and with this in position
it is possible to examine a microscopic area as distinct from a microscopic
speck, and at a distance of 9 to 12 inches. This short attachment also
provides one with the finest compound corneal microscope ever made. The
patient is seated so that a light falls upon the eye and the micro-telescope is
focused upon it at a distance of about a foot, and the resulting view is sur-
prising. A further and very interesting feature is the ability to do both
micro- and tele-photography with it. For this, however, a certain type of
microscope is necessary, as the tube containing the eyepiece must be removed
so that the camera may take its place. For long-distance photography, both
the long and the short focus lenses are inserted in the short tube, and the
combination forms the tele-photo lens. We have seen some really fine speci-
mens of both forms of photography, viz., the proboscis of a fly, and a view of
shipping taken 3^ miles away. Messrs. F. Davidson & Co.
of 29, Great Portland Street, W., are the inventors of this
instrument. The cost of addition to an ordinary micro
scope of the long or short attachment is

Nebulizer (Rogers’ Pocket). — This was
devised specially for use with Rogers’ Coryfin
Solution, but is equally suitable for nebuUzing
any other light oily or glycerinated solution;
it will also, on the score of its portability and
convenience, appeal strongly to the users of
asthma solutions, who find the usual form of
asthma apparatus cumbersome and objection-
able except in private. This little nebulizer
is simple and strongly made. The bellows, |
while not unduly large, has sufficient capacity '
to supply the necessary force of air, a point
which is often overlooked in designing portable Fig . 14 1 .

instruments of this class. The glass portion

is perfectly protected by the neat, strong case provided {Fig. 141). Frank
A. Rogers, 327, Oxford Street, W.

APPLIANCES

MEDICAL ANNUAL

7£0

Operating-table. — This table (Fig. 142) lias been designed to meet the
demand for a cheap apparatus giving perfectly the Trendelenburg and

all other movements obtainable in
tables, with the additional advantage
of raising and lowering. It is easily
raised or lowered by slight force
exerted on the mechanism, which
combines the lever and counterweight
principles, and gives a maximum
height of 42 inches and minimum
height of 34 inches. It can be confi-
dently recommended, and is sold
complete with one pair of combined
foot and shoulder rests, and one
pair of lithotomy stirrups, for £2$,
b}^ the IMedical Supply Association,
Gray’s Inn Road, W.C.

Portable Operating Table {Fig. 143).
— ^This has been designed for Sir Ber-
keley jMoynihan by C. F. Thackray,
of Leeds, and has for its main
features lightness, and the ease with
which the Trendelenburg position
can be attained, by simply rotating
a right and left handed screw
shaft, by means of a handle which
in turn works two pairs of pivoted scissor-like arms. This movement is
constructed of finest quality steel, although the greater part of the table
is made of an allo}^ of aluminium. The table is very light (actual weight,
24 lb.), and yet stands quite firmly. The head and foot-piece can be fixed

at any angle. When folded to fit into a waterproofed canvas case it measures
41 in. in length, 23 in. in breadth, and 5^ in. in depth, and can be obtained
complete with stirrups, shoulder-pieces, etc., if so desired. It costs £1$ 15s.,
and w^e can cordially recommend it.

editor’s table

APPLIANCES

Oxygen Bottle. — ^We illustrate in Fig. 144 a convenient arrangement by
which oxygen can be warmed and medicated with nitrite of amyl or iodide

of ethyl before passing to the patient in cases

of angina. When it is desired to give a diffus- /'* —

ible stimulant, ether may be employed in a .

similar way, or a quantity of rectified spirit, Vf

brand}", or whisky may be poured into the lower

part of the flask and oxygen allowed to bubble jlj ri

through it. The bottle may also be used simply !>

to render the oxygen warm and moist. In this ^rrVi ■

latter case the bottle is half filled with hot

water and placed in a small basin of hot water, JJ MB!

or surrounded by hot wet flannels. In some ll*' — '

cases of bronchitis it may be advisable to add jijj , li yi,

to the hot water Friar's balsam, terebene, j f' j||' |'l|

or other terebinthine preparation. It was j jj 'Ii|^ il|i|

suggested by Sir Lauder Brunton, and is 'I' jj '|| llji

made by Allen &' Hanburys Ltd., 48, W^igmore i 'I ; 1 1 |

street, W. ' ■ f; I »

Oxygen Face-piece. — This is malde of
7 1 glass with metal mount and tube,^ shaped

L ;•-; >?/ i JiS to fit the contour of the face. It is easily

Yl|WP/ sterilizable. The curved metal mount can be

turned to any position 145). It is very
Fi^. convenient in use, and most practicable,

Nci/ * Costs 6/6. Reynolds & Branson Ltd., Leeds.

Pneumothorax (Artificial Induction of). — A very simple and practical
apparatus for the induction of artificial pneumothorax is supplied by
Messrs. Reynolds cS: Branson, of Leeds, who furnish full directions for
use, and also a pamphlet giving suggestions for the operative procedure.
The nitrogen is obtained from the atmosphere, the oxygen being absorbed
by alkaline pyrogallate, nitrogen then being available. It has been used
with perfect success at the Armley Hospital for Consumptives, Leeds, and
^ in the tuberculosis wards of the Leeds City

J Hospitals. W^e give an illustration of the

I apparatus (Fig. 146), and also one

showing the needle fitted with a
hypodermic syringe for the vein
test (Fig. 147. Price complete,

Fig . 146.

APPLIANCES

712

MEDICAL ANNUAL

Pocket Causes* — The Aseptic Miniatuye Pocket Case is about the size of an
ordinary cigarette case [Fig. 148). It contains miniature but quite efficient
® instruments to meet the

very minor surgery of
everyday practice. There
is a two-bladed knife —
full size, wdth curved
abscess blade, and also
tenotomy blade — an ex-
cellent exploring-needle
director, and probe, which
when screwed to holder
make full-sized instru-
ments. There are scis-
sors, and artery and
dressing forceps, which
are small but quite useful
The aseptic metal case is
enclosed in a chamois
purse, and we find that
a tube containing a
suture and needle in
aseptic solution wdll fit
into the purse with the
case [see Ligatures, Emer-
gency, p. 707). We re-
commend this addition

as it will enable us to meet cases of wounds requiring sutures. Price 17/C.
R. Sumner and Co., Liverpool.

The " Surgman Flat Metal Pocket Case, for waistcoat pocket [Fig. 149),
contains three all-
metal knives, i.e.,
one each Paget's,

Syme's, and scalpel,
and costs 7/6 com-
plete. The Surgical
Manufacturing Co.,

85, Mortimer St., W.

Pyne-U-Ca Health
Box, — A simple at-
tachment to the cis-
tern of the lavatory
which ensures the water being charged with a disinfectant when the chain
is puhed. It costs 2/6, and a renewal charge for 1000 lavatory usages
costs tenpence. The method is much in use, and the fluid has
great antiseptic power. The Medical Supply Association,
London, W.C

Retractors. — Doug-
las Shield's Retractor
is a new form possess-
ing many good points.
It has been found
extremely useful in
cases of appendicitis,
goitre, and general
operative work of this
description. The cross
handle is an advantage, saving the aching and tiring of the fingers or hands
of the assistant in a lengthy operation [Fig. 150). Allen & Hanburys Ltd.

Fig. 149.

Scales

Fig. 150.

editor’s table

713

APPLIANCES

Abdominal Retvactor. — In many abdominal sections a suitable exposure of
the field of operation adds considerably to the facility of their performance.
This is particularly true in gynaecological work, in which the depth of the
pelvis affords additional difficulty in any surgical procedure. Frequently a
retractor is needed that not only gives ready access to the site of operation,

but is of simple design and manipulation. It should be capable of easy
enlargement, and it should be possible to alter the position or inclination of
any blade without interfering with the instrument as a whole. To meet
these conditions, Mr. Harold Chappie, Obstetric Surgeon at Gaya’s Hospital, has
devised the abdominal retractor shown in the illustrations [Figs. 1 5 1-152) . It
is simple, light, of small bulk, and introduced
with ease. After introduction, it is self-retaining
and remains absolutely fixed, and attachment
or detachment of any blade can be speedily
accomplished. Enlargement is readily effected
in either direction. Special blades have been
also devised for attach-
ment in any position at
either end of the retract-
or ; e.g., in pelvic work,
the intestines, after be-
ing packed off with
gauze, are held aside by
special framework
[Fig, 152), which is con-
nected to the frame of
the instrument. Down
Bros. Ld., St. Thomas’s
Street, London.

Balfour s Three-bladed
Abdominal Retractor,
which we illustrate here
[Fig, 153), is simple,
easily adjusted, and
rigid. It costs 25 /-.

The Holborn Surgical
Instrument Co. Ltd.

Eyelid Retractor. — The instrument illus-
trated [Fig. i‘54) has been devised by Mr.
C. G. Russ Wood, F.R.C.S., of Slire-wsbury.
The lower part of the shank is malleable, so

Fig . 153 .

Fis . 154 .

APPLIANCES

714

MEDICAL ANNUAL

that it can be adjusted to a prominent orbital margin; at the same time
no pressure whatever is caused on the eyeball itself. The solid upper blade
presses the cilia out of the way of any instrument which is being used
on the globe, and w^hen in use the shank rests on the forehead, so that
only slight pressure from the bent finger is required to retain the elevated
lid in its place. Down Bros. Ltd., St. Thomas's Street, S.E.

“ Salivoyds.” — Under this name compressed pads are prepared for absorbing
the saliva. They should prove especially useful to dentists. The Medical
Supply Association.

Salvarsan Apparatus. — Mr. Alfred Ailport has designed a convenient
portable outfit for intravenous injection (Fig, 155) . It consists of an ordinary
round sterilizing drum, into w'hich is fitted a metal tank about 4in. deep.
Into a rack somewhat like a cruet-stand with a handle, fits a 20-oz. graduated
measure for mixing the solution, a glass rod, and
a small 50 cm. measure for the sodium hydrate
solution (if neo-salvarsan be used, these two
measures are not needed) ; two 300 cm.
graduated glass vessels (Ehrlich), one
for the saline solution or distilled water,
and one for the salvarsan or neo-salvar-
san solution ; a 30-oz. stoppered bottle
for the saline solution or distilled water,
and two clips for the glass syringe.
After an injection has been given, the
Ehrlich glass which contained the sal-
varsan solution is thoroughly well rinsed
three or four times by
vigorous shaking with
the saline or distilled
water which has been
left over from the oper-
ation, the covers are
put on both glasses, and
they are replaced in the
rack with the other ware ; the rack is fitted into the drum, and the whole
outfit sterilized in the sterilizer. There is room on the top of the vessel for
a couple of towels and some dressings. The injection needle is a slight
modification of McDonagh’s needle. It has a more convenient handle, and
a plain flat plate by wduch it can be secured to the limb with a small strip of
adhesive strapping. The whole apparatus in its sterilizer drum fits into a
canvas waterproof cover with a leather handle for carrying, and is very
compact and portable. Down Bros.

Ltd.

Salvarsan Needle (Iniravenoits ). —

\Xe illustrate in Fig. 156 the form
of needle which is in regular use at
St. Bartholomew's Hospital for intra-
venous injection. The tube wdth plug
is used to make sure the needle is in

the vein. The Holborn Surgical Instrument Co., 26, Thavies Inn, E.C.

Salvarsan Syringe . — The salvarsan syringe (Fig. 157), which has been
made to the design of jMr. H. L. ^^^lale, claims to possess the following advan-
tages over the S3Tinge in ordinary use : (i) Large capacity, 100 c.c. ; two
syringefuls complete any dose ; this saves time and minimizes the leakage
of air, which enters every time the two-way tap is turned for refilling. (2) A
surrounding metal cage, protecting against breakage. (3) The end-piece,
bearing the nozzles, is of metal ; this also minimizes the chance of breaking.
(4) Both nozzles are bulbous, not cylindrical; these fit the tubing more

EDITOR S TABLE

APPtlANCES

715

tightl5L allowing less leakage of air. (5) The tube which lies in the solution
is weighted. (6) The needle is fitted 'with a stylet, so arranged that if the
former be blocked by a subcutaneous blood-clot, it can be cleared without

Fis. 157 -

removal : this avoids the pain of repeated skin-punctures. Mayer & Meltzer,
71, Great Portland Street,

Screw and Screw-driver for Operative Treatment of Fractures. — The

screw-driver, as shown in Fig. 158, has projecting from its end prongs, four
in number, which fit into corresponding notches at the margin of the head

of the screw. A very secure “ bite ** is thus obtained, the screw-driver
having no tendency to slip ofi the end of the screw, as so often happens
with the form in common use. It is also more easy to drive the screw
straightly home, there being no tendency to
deviation. The screw-driver is magnetized, so
that the screw can be carried to the bone on
its end, and placed in position without any
screw-holder. Nothing, therefore, should touch
the screw after it has once been put in place on
the end of the driver. The scre^v can be driven
in flush with a Lane’s plate, as the end of the
driver is the exact size of the head of the screw.

The advantages over the ordinary screw-driver
and screw are the more secure" ** bite ” and
the portability gained b>' magnetization. Allen
& Hanburys Ltd., 48, Wigmore Street, W,

Spirit Lamp (Improved). — The ordinary spirit
lamp is a very crude afi'air. Tliis one has a
nickel-plated burner, with arrangement for
regulating the flame and putting it out before
the cap is applied. It is an enormous advance
on the ordinary form. Price 3 /6. The Medical
Supply Association.

Splint Material {Fig. 159) .—Under the name
of “ Pexuloid ” a new material has been intro-
duced which is of a celluloid character, but not
inflammable. It is very light and rigid, and
a very perfect model of the part can be pro-
duced. It is necessary for the surgeon to make ’

a plaster cast of the part for which the splint
is required, and from this the ** Pexuloid "
appliance is made. For splints which have to 159-

APPUANCES

716

MEDICAL ANNUAL

be worn for a considerable time it offers many advantages, as regards
both lightness and cleanliness, over existing materials. It can be taken off
and sponged when necessary, and then put back by simply lacing it.
Pliilip Harris & Co., Edmund Street, Birmingham.

Sponges (Surgical). — Bernay’s sterilized compressed absorbent cotton
sponges will open out to ten times their thickness, and have as much aosorb-
ing power as a large-size wad of gauze or wool. They are supplied in boxes
containing four dozen sponges, at 3/6 per box, by the Medical Supply
Association, Gray's Inn Road, W.C.

Spray (Dental and Medical). — ^This spray {Fig. 160) is designed by Mr.
Frank A. Rogers for dental work, where a strong effective spray is
required, but we do not see any reason why it should
be limited to this purpose, We are very sceptical
about sprays, as so much rubbish is put upon the
market. It is an appliance which has usually gone
wrong when one wants to use it. In this spray the
tube is glass all through, of a sulhcientlj'' wide calibre,
so that it will not be easily occluded. It has a
conical bottom, so that small quantities of fluid
can be used with a spray of full size, wdth the result
that greater power is obtained. The stand is made
of india-rubber on the suction principle, so that it
adheres firmly to the glass or polished table and
cannot be overturned. The spray is lifted out of the
stand when required for use. We consider all the
essential principles of a really practical spray have
been combined in this instrument, and further modi-
fications can be made in adapting the nozzle to the
nose, pharynx, etc., w-hich we hope the manufacturer will do. Frank A.
Rogers, 337, Oxford Street, W.

Spray Tube. — ^The ‘‘ Grevillite " automatic spray tube requires no spray
bellows. It is a tube, with cork attached. All that is necessary is to place
the tube in a bottle of fluid,
pass the finger through a ring,
and work the spray tube up
and down, by which a very
powerful spray is obtained.

While well adapted for spraying
rooms, etc., it would not keep
the spray directed on a definite
point, so that it would not be
suitable for the throat. Price
2/3. The Medical Supply Associ-
ation, Gray's Inn Road, W.C.

Bristol Auto - Spray.” — A
similar auto-spray is supplied
by Messrs. Ferris and Co. Ltd.,
of Bristol.

Spring Balance. — The dis-
advantage of the basket up-
setting is avoided in this scale
{Fig. 1 61). It is easily slid into the balance and cannot be upset. It is
graduated in ounces to weigh up to 20 lb., and costs 18/6. The Holborn
Surgical Instrument Co., 26, Thavies Inn, E.C.

Sterilizers for Dressings. — A new sterilizer with vacuum attachments
{Fig. 162) has been produced, which will render dressings absolutely sterile
and dry in thirty minutes. The drum measures lojin. by y^in. It is

Fig. 161.

editor's table

717

APPLIANCES

fitted ■s\ith a Bunsen burner, and costs, complete with stand, £6 los. The
Surgical Manufacturing Co., 85, Mortimer Street, London, W.

Another sterilizer {Fig. 163), produced by Messrs. R. Sumner & Co., of
Liverpool, uses super-heated steam for purposes of sterilization. It is made

APPLIANCES

718

MEDICAL ANNUAL

folding legs, which re\'ersc and form a lock fur holding the lid in position. It
has two burner lamps. Size Sin. by 2in. by ain. This is the cheapest and
most practicable sterilizer for small instruments which has come under our
notice. The Medical Supply Association.

A cheap sterilizer, for small instruments, forceps, scissors, etc., is made of
an iron enamelled mug with wire gauze tray, heated by means of a Bunsen
burner or spirit lamp [Fig. 165). It measures 4 in. deep by 5 in. diameter,
and the price without burner is 5 /-. This is well suited for surgery or hospital
use, but is not portable. Made by Reynolds & Branson, Leeds.

Sterilizer for Sutures. — k. glass jar with ground-in
glass stopper, containing a metal frame for holding
six tubes of sutures immersed in alcohol. Mlien
recjuired for use, the frame is drawn to the top of
the jar and held there by two hooks. Price, complete
with sutures, 7 /6. A larger size, to hold eighteen
tubes, 10/6. The Medical Supply Association.

165.

Fig. 166.

Sterilizing Box for Gloves. — Fig. 166 illustrates a very convenient appli-
ance for sterilizing and carrying india-rubber gloves. Produced in various

sizes by the Surgical
Manufacturing Co.,
Mortimer Street, W.

Stethoscope. — This has an aluminium
chest-piece [Fig. 167) which is made to
revolve for convenience in examining
the back and sides of chest. It has a
hinged spring, and tubes of equal calibre
throughout. Designed by Dr. Gordon
Copeland, and manufactured by Allen
and Hanburys Ltd.

Stomach Evacuator.— The advantage
of this stomach tube is its simplicity and
cleanliness. The contents of the stomach
can be drawn into the bottle and taken
away for examination, a rubber stopper
and cap being supplied to close the bottle.
The illustration [Fig. 16S) will show the
simple mechanism of the invention, which
is exceedingly practical. The Holborn
Surgical Instrument Co. Ltd.

FiS‘ 168.

editor’s table

719

APPLIANCES

stomach Ttihe . — “ Lonings ” india-rubber stomach tubes have two eyes
and closed ends. These tubes being oval, they are more easily introduced,
especially in cases of slight oesophageal strictures, and have thick walls
which prevent the tube collapsing while in use. Price 7/6 each, from the
Medical Supply Association.

Surgical Cases. — [See Aseptic Instruments, p. 689.)

Suspensory Bandages. — Under the name of the Stow-away,” the Domen
Belts Co. Ltd., 456, Strand, W.C., have produced the most comfortable
and efficient suspensory bandage which has come
under our notice [Fig, 169). The cover is made
of wdiite cotton or pure wool, and the testicles
are held well up by means of elastic bands. We
can highl^r commend this support. The cost is
from I /6 to 5 /-, ^according to quality.

Suture and Ligature Spool- Attachment— 3 Mr. B.

Bichardson Billings has devised a suture and
ligature spool, whereby rapid and easy suturing
and ligaturing can be accomplished [Fig. 170).

The apparatus is a substitute for the more ex-
pensive " sewing machines which have been devised from time to time,
and consists of a light metal reel on a framework, which can be attached
to most of the needle-holders in common use, or even to a pair of Spencer
Wells’ artery forceps. The reel has deep flanges, which are perforated,
allowing for thorough sterilization of its contents. Its axle is instantly
unmountable from the frame, by the turn of a milled nut on either side.
The needle is half-curved, with the eye at the point ; and, unlike the

ordinary variety, once it is
in the holder it need not be
released. This alone saves
some seconds per stitch.
The needle is threaded and
passed through the tissues
in the ordinary way, the free
end is then gripped wdth for-
ceps, and the needle brought
back again through the hole
made, along the thread,
which is then cut between tissues and needle. This is one suture made, and
the needle is ready for the next. A continuous suture can be adapted with
slight modification, while for rapid ligaturing the advantages arc obvious.
The attachment is cheap, adaptable, simple, efficient, clean, instantly
changeable (allowing different materials or sizes to be used), time-saving,
and practical. The Holborii Surgical Instrument Co., 26, Thavies Inn, E.C.

Syringe (Record Type). — ^This instrument is graduated to So min. [Fig.
1 71), with very fine electro-plated nozzle to fit ureteric catheters. It

Fig . 171.

IS recommended by Mr. Thomson Walker for washing out ureteric
catheters, and also for wasliing the pelvis of the kidney. Allen & Hanburys
Ltd., 48, Wigmore Street, W.

APPLIANCES

720

MEDICAL ANNUAL

Syringe Forceps.

-As will be seen from Fig. 172, these forceps are handy
for picking up syringes, etc., which the ordinary
pattern of sterilizer forceps will not do. The Holborn
Surgical Instrument Co. Ltd. supply these.

Test-tube Holder. — ^This is designed so that it can
be attached to the spirit lamp. The tube can be
fixed at any angle. It is quite ingenious and prac-
ticable. Price I /3, from the Medical Supply Associ-
ation.

Test-tube Stand. — ^This is a metal stand for holding
test-tubes or bottles, in sets of three sizes. The
test-tube is passed through the stand, so that the
spring portion of the stand fitted with the metal plate
rests on the table and will hold the test-tube up-
right. Price 1/3 per set, from the Medical Supply
Association.

Tongue Depressors. — The handle of this instru-
ment (Fig. 173) has an admirable grip, and the
blade being narrow allows the full view of the
tongue, and cavity of the mouth. We have found
it most efficient in cases of high-backed tongue.

The shape gives greater control than the ordinary tongue
depressor. Price 3 /6.

Double-Ended Metal Fenestvafed Tongue Depressor (Fig. 174); —
This is also a very handy depressor, the fenestrations admitting
a good view of the surface of the tongue, but it does not compare

Fig. 174.

in efficiency with the above instrument. Price 2/6. R. Sumner
and Co. Ltd., Liverpool, supply both these instruments.

Tonsil Enucleator.— IMr. Howard 'Warner, M.B., has designed an
enucleator (Fig. 175) for use in the complete removal of tonsils of
the following types : (^i) The ordina^ enlarged tonsil, over the
anterior surface of which the anterior pillar, of the fauces is

Fig. I7S* Fig. 173,

spread and firmly adherent, (b) The small, fibrous, embedded tonsil, the
subject of repeated attacks of follicular inflammation, which cannot be
properly introduced into the guillotine. In using the enucleator the tonsil
is grasped with fixation forceps and pulled gently inwards, and the mucous
membrane is divided with the extreme tip of the enucleator (which is the
only part approaching to sharpness) between the anterior pillar and the

editor's table

721

APPLIANCES

tonsil. The curve of the blade enables the operator to separate the body
of the tonsil completely from its bed, working from above downwards, and
finally the lower pole, which is hanging only by mucous membrane, may
be separated. The enucleator is double-ended, thus being suitable for either
tonsil, and is curved slightly on the flat ; this does not show in the illus-
tration. The blades are quite blunt, except the extreme tips, which are
half-sharpened only. The Holbom Surgical Instrument Co.

Tonsil Forceps. — ^The instrument illustrated {Fig. 176) will be found of
particular advantage in dealing with tonsils that are not easily accessible

FULL SIZE

to the guillotine alone. The distinctive features are : (i) The blades curve

sharply at right angles close to the jaws ; the jaws open and close in the

vertical plane, thus enabling the operator easily

to get a firm grip of the tonsil; (2) The jaws 1 -

have short, saw-shaped teeth, giving a firm hold

and affording plenty of room between the blades

when opened, an advantage in working in the

small space available ; and (3) The instrument passes con-

veniently through the fenestra of a guillotine or the loop of a

snare. Designed by Arthur J. Hutchison, M.B., and made by Jj

Down Bros. Ltd.

Tonsil Probe. — The instrument here illustrated {Fig, 177) has /|

been devised by Mr. H. Tilley, to expedite the examination of J

imbedded tonsils. If the outer portion of the tonsil is pressed A

upon, the gland tends to face the observer, and septic accumula- I A

tions may be expressed that otherwise might pass unnoticed,

It is useful for obtaining a more complete view of inconspicuous ,
tonsils which often conceal septic accumulations. It may also be «
used in cauterizing or operating on tonsillar crypts. Mayer and ■
Meltzer, 71, Great Portland Street, W. ;

Truss (Adjustable Elastic). — ^We have been much interested in
this appliance, which is an entirely new and very desirable depar-
ture in the manufacture of trusses. It has a soft adjustable elastic
band {Fig. 178), of sufficient strength to give a perfect retention
without discomfort. There is a double line of draft over the ^ 77 -

front piece and pad, whereby the pressure can be regulated and applied

to either the top or the

Fig. 17S.

bottom of the pad, as
may be required. This
enables an even inward
and upward pressure to
be obtained on the pad
without pressure on the
understrap. It also has
a new air-cell pad, made
in all shapes and sizes
to fit the body correctly.
The steel spring round
the body is done away
wdth. It makes it easy
to fit the patient comfort-

APPLIANCES

722

MEDICAL ANNUAL

abl}^ and apply the pressure just as wanted. The cost is quite reasonable.
William S. Rice Ltd., S, 9, Stonecutter Street, E.C. are the makers.

Tuberculin Cases. — Fig. 179 illustrates a portable case designed by Dr.
Hyslop Thomson, containing every requirement for use by tuberculosis
officers and dispensaries. Made by Allen & Hanburys Ltd.

We also illustrate (Fig, 180) another tuberculin outfit suggested by Dr.
E. H. R, Harries, and made by Down Bros. Ltd.

Urinals. — ^The efiectual cleansing of earthenware urinals has hitherto
presented some difficulty owing to the need for construction in a form designed
to ensure the retention of their contents when in use. Sister Hodnett, of

editor's table

723

APPLIANCES

the West Ham Infirmary, has designed an improved model {Figs. 18 1, 182),
which, while in nowise departing from these lines, provides in addition an

Fig. i8i.

Fig. 1S2.

aSc

Fig. 183.

opening which will admit the hand or a mop for thorough cleansing. Down
Bros. Ltd., St. Thomas’s Street, S.E.

Female Urinal . — The “Christie” urinal (Fig. 1S3) helps us to solve a
problem. There is always a difficulty in getting
the female patient to pass water in the dorsal
position. The shape of the vessel under notice,
and its open character, has much to recommend
it, and it should prove of great convenience.

The Hospitals and -General
Contracts Co, Ltd., 25-35,

Mortimer Street, W.

Urine Specimen Glass. — Drs.

Rideal and Beddard have intro-
duced an improved specimen
glass (Fig. 184),, the advant-
ages claimed being a small calibre, so that about i oz.
of fluid will freely float an ordinary urinometer ; a blunt
conical bottom to enable sediment to be collected, and
for ease of cleaning; and a funnel-shaped top to hold
filter paper. Down Bros. Ltd.

Vaporizers. — A very inexpensive and efficient vaporizer,
the “ Ariel ” (Fig, 185) has
been introduced by the Hol-
born Surgical Instrument
Co., 26, Thavies Inn, E.C.

It has a great variety of uses both in the
sick room, and also for domestic purposes.

It is heated by a small lamp burning ordinary
petroleum, and any form of medicament can
be vaporized, such as pine oil, eucalyptus,
oil of lavender, carbolic acid, etc. It also
acts as a night-light in the sick room. It
is a w’ell-made, ornamental, and practical
appliance, and we can recommend it. Cost,
complete, 2 /6.

X-ray Apparatus (Rotary High Tension). —

A’-ray workers have been specially interested
during the last year or two in the various
rotary high-tension rectifiers that have been
put on the market. They have in most
cases been far from satisfactory for various
reasons, but principally because they produce
inverse current in the tube, and because of
the rapidity with which they destroyed the 1S5.

,r-ray tubes. Another defect was the failure

of the insulation. Other disadvantages were the noise of the apparatus
when working, and the large amount of floor space that it occupied. These

Fig. 1S4,

APPLIANCES

724

MEDICAL ANNUAL

defects have been eliminated in the new apparatus recently perfected by
Hr. Gaiffe. The best testimony of its value is that it gained the unique
award of the Grand Prix at the recent International Medical Congress in
London, in August, 1913, where it was in competition with all the well-
known instruments of its class.

From the illustration (Fig. 186) it will be seen that the Gaiife apparatus
differs essentially from all preceding rectifying machines. It is of vertical-
type, and the ground space it takes up measures only 2ft. gin. by 3ft. ; the
height is 5ft. 4in. It is of all machines the most silent, and is absolutely free
from vibration. One great advantage of the
apparatus is its remarkable flexibility : it serves
equally well for treatment-work requiring the
smallest current, and for rapid radiography
requiring the most powerful. The spark can
be varied by delicate adjustments between the
minimum of less than | in. to the full distance
between the discharging pillars. The discharge
in the tube is absolutely free of inverse current,
the strain on the tube is reduced to the mini-
mum, and as a result, the length of life of the
tube is" greater than on any other form of
apparatus, greater even than on an ordinary
coil working from an interrupter.

For screen work the illumination is steady.
Breakdown is not likely to occur, because the
insulating material, consisting neither of wax,
resin, nor oil, can be absolutely relied upon.
The macliine does perfectly for high-frequency
work, giving very fine effluves, and on the
couch, a milliampdrage of much greater range
than is required for medical practice. The
apparatus works either on continuous or alter-
nating current, and the price, £150, includes
a movable switch-table mounted on easy-
running casters, which can be wheeled to any part of the x-iay room.

If this apparatus is supplied to wmrk on continuous current, the price
includes a synchronous motor, which converts the continuous current into
alternating, the phases of which alternating current are used in the production
of the A'-rays. Agents, the Medical Supply Association.

PROGRESS OF PHARMACY, DIETETICS, &c.

Aeitrin, sold by the Bayer Co. Ltd., 19, St. Dunstan's Hill, E.C., in J gram.
(7-1 grs.) tablets, is described as an ethyl ester of phenyl-cinchoninic acid.
It is destined for use in gout as an eliminant of uric acid, and like other
preparations of allied chemical composition such as atophan, is receiving
considerable attention at the hands of German clinicians (see p. i).

Adamon, for which we are also indebted to the Bayer Co., is a combination
of bromide and valerian, without the unpleasant characteristics of the latter.
We have given this drug a restricted trial and found it efficient and pleasant.
It is particularly indicated in neurotic conditions, on which it exercises a
mild sedative action. In mild cases one tablet (7I grs.) is given three or
four times daily ; while two tablets given shortly before bedtime are of
value where there is excitement with a tendency to insomnia. We have
pleasure in stating that extended experience has confirmed our favourable
impression of Adalin, another bromide compound used as a mild sedative
winch is issued by the Bayer Co. For insomnia of a mild order, such as is
encountered in neurasthenics, we have found it very useful.

editor's table

725

PHARMACY

Agmel (Succus Agavss Concentr.) is a preparation with an interesting
history. Since the sixteenth century the Mexicans have used “ aguaniiel,’*
the fresh sap of the pulque maguey, in the treatment of renal and urinary
inflammations ; but of late years its reputation has spread beyond the
country where it is indigenous, and it is said that renal patients are being
sent to Mexico from other lands lor an “ aguamiel cure.” Encouraged by
this, the local pharmacists have prepared “ Agmel ” — a concentration of
aguamiel to the consistency of honey — ^for foreign sale. The British agents
are Messrs. Mase & Partners, 15, King Street, West Smithfield, E.C. It is
usually administered in doses of a tablespoonful, freely diluted with w’ater,
three or four times daily ; dilution may be dispensed with, but the sickly
sweetness of the preparation will be found too much for most stomachs
unless it is watered down. According to Dr. C. S. Dolley, of ^Mexico City,
“ it is most widely used in diseases of malnutrition, especially w^here this
has led to diseases of the kidneys and bladder.” The results of a critical
examination of this drug, such as is likely to be undertaken by vaiious
observers, will furnish interesting reading.

Airol (The Hoffmann-La Roche Chemical Works Ltd., 7 & S, Idol Lane,
E.C.). — This is an oxy-iodo-gallate of bismuth, sent out in powder form, for
use as a dusting powrder, as an unguent, or in suspension. It is said to combine
the antiseptic action of iodine, which is liberated by contact with moisture,
with the astringent properties of gallic acid and the absorptiveness of
bismuth ; and is therefore of value in the treatment of ulcers, granulating
surfaces, intertrigo, etc.

“ Aseptoid ” Mercuric Soap. — This soap, prepared by Messrs, Oppenheimer,
Son & Co., Ltd., contains 2 per cent of mercuric iodide. This is well known
to be an excellent antiseptic, powerful and yet not injurious to the tissues ;
while the soap itself is pleasant, bland and non-irritating to use. Whether
these soaps are so powerfully antiseptic as they would seem to be from
theoretical considerations, it is very hard to judge except by actual experi-
ment ; the manufacturers claim that this preparation has a Ingh bactericidal
coefficient.

“ Bisedia»’’ prepared by Messrs. Giles, Schacht & Co., Clifton, is so well
known that any recommendation seems almost superfluous. It is a com-
bination of Schacht's liquor bismuthi wdth liquid pepsin and sedatives
(morphine hydrochlor. gr. ^.c. hydroc^^an. dil. Til., ij, drachm). As a

gastric sedative in the various disorders and diseases of the stomach that
are associated wdth obstinate vomiting, w’e have found this a most reliable
combination. It has the advantage of being pleasant in appearance, smell,
and taste. The name “ Bisedia ” has been adopted in the place of the
former “ Liquor Bismuthi Sedativus ” to guard the public from worthless
imitations sold under the above title.

Bismuth and Pancreatin, — The special claim of this preparation is that
it combines the alkalinity wffiich is essential to the proper action of fluid
bismuth preparations, wdth pancreatic ferments w^hose proteol3rfcic action is
not interfered wdth by the presence of a small quantity of alkali. The dose
is I to 2 dr., and it is prepared by Mr. W. Martindale, 10, New Cavendish
Street, W.

Bismuth Gauze. — ^^lessrs. Burroughs, Wellcome & Co. have sent us a
“ tabloid ” parcel of this form of dressing. It contains six neat little rolls
of gauze, each a yard long and half an inch wide ; each roll is sterilized and
enclosed in a covering which keeps it sterile. This size is specially destined
for use in ear, nose and throat work.

Brain Extract. — Mr. W. Martindale sends us this new effort in organo-
therapy. It was prepared at the instance of Dr. Maule Smith, of Bromsgrove
Asylum, for use in cases of dementia, delusional insanity etc., and is said
to have produced good results in these conditions. It is made from the
brains of healthy fuU-grown sheep and cattle.

PHARMACY 726 MEDICAL ANNUAL

Carlsbad Sprudel Salt, Natural. — ^Messrs. Ingram & Royle Ltd., warn the
profession that in prescribing this they must specify the natural salt, since there
are many artificial preparations on the market.

Cerettes are neat flexible gelatine containers filled with ointments or
medicated soaps. To use, the extreme tip of the container is cut off and
the contents used as required. This is a conveniently portable packing for
unguents, free from the disadvantages of contact with metal. The sample
sent us by the makers (Messrs. Oppenheimei, Son & Co., Ltd.) contained a
yellow oxide of mercury ointment with atropine and cocaine, an ointment
frequently wanted at short notice by the medical man ; these “ cerettes
are eminently suited for carriage in the bag. '

Coagulose is a Parke, Davis haemostatic ferment obtained from normal
horse serum. It is sent out in sealed bulbs, each of which contains a single
full dose. Directions as to dosage and administration are given with each
package. In the present volume various references will be found expounding
the value of this form of therapy in haemorrhagic conditions.

Collosols are colloidal preparations of metals, made by Messrs. Oppenheimer,
This is a new step in pharmacology, the object being to offer the practitioner
the antiseptic properties of silver, mercury, etc., in a form innocuous to the
human subject. “ Collosol Argentum and “ Collosol Hydrargyrum ” are
said to fulfil the purpose equally well, preference being given to the latter
in cases with -a S3’philitic taint. “Collosol Ferrum is intended for use
wherever iron is indicated for medicinal purposes. They may be given by
intramuscular or intravenous injection, or by mouth ; in the latter case
they must be given an hour or tw^o after a light meal and no further food
taken for at least two hours, since they absolutely inhibit digestion. They
are issued in 4 oz. bottles and in sterile “ Aseptules ” each containing 15
minims.

Copper, Colloidal. — ^This is also an Oppenheimer product, sent to us in
“ Aseptule ” form. Administered by hypodermic or intramuscular injection,
it is said to yield astounding results in cancer. We hope this may prove
correct, though some of our experiences in this direction have not been
altogether encouraging. In so dire a disease, however, ever)?' means of
cure deserves the fullest consideration and trial.

Cosmin. lodl Decolorata (Messrs. Sumner & Co. Ltd., Liverpool). — The
use of iodine ointment has been great!)’' extended in recent years by the
fact that non-staining preparations are now available. The ointment now
under notice belongs to this category, and is a singularly successful example ;
it contains 5 per cent of iodine loosely combined with a purified hj^drocarbon
basis. It costs 4/- per lb.

Cream of Malt with Sicilian Olive OH. — This is a highly satisfactory com-
bination of an easily assimilable fat, in a pure form, with malt of a high
diastatic activity. The manufacturers, Messrs. Oppenheimer, Son & Co.
Ltd,, have issued quite a series of “ cream of malt " preparations, of which
this is one.

Crolas Oil, sent to us by M. Bresillon & Co., Gamage Buildings, Holborn,
E.C., is a tasteless, odourless preparation of castor oil, a drug which never
goes out of ‘fashion. It is a remarkably successful product in its disguise
of the unpleasant qualities that have made castor oil a by- word in generations
of nurseries.

Cuprokrol (jMessrs. Reynolds & Branson Ltd. Leeds) is a copper ointment
with the astringent and parasiticide properties of that metal, presented in a
pleasant form for use in tinea and similar affections of the skin.

Gycloform Co., Bng. (The Bayer Co. Ltd.). — This contains a benzoic
acid derivative, cycloform (10 per cent!, with antiseptic and aiicosthetic
properties, vfith hamamelis and oxide of zinc. It forms a pleasant and
soothing emollient, which may be used on a large scale without fear of toxic
effects.

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727

PHARMACY

DIabstic Foods. — ^Messrs. Callard & Co., 74, Regent Street, W., call our
attention to the emphasis laid upon diet in diabetes, at the recent inter-
national congress, and to the foods with which their name is inseparably
associated, such as Casoid ” bread. We need do no more than remind our
readers of the long and unique experience which this firm has enjoyed in
catering for the needs of sufferers from diabetes.

INIessrs. Maurice & Co., Bedford Chambers, Covent Garden, W.C., have
also forwarded us samples of biscuits intended for diabetics. Some of these
biscuits are stated by the makers, Rademann’s Nahrmittelfabrik, to contain
as follows: — Diabetiker Bis., 32 per cent proteids and 33 per cent carbohy-
drates ; Diabetiker Bretzel, 32 per cent proteids and 40 per cent carbo-
hydrates.

Other biscuits (Fleur de Neige, Longuets, Madeleines and Exquis) are
manufactured by the firm of Charrasse of Marseilles under the supervision
of Dr. B. Charrasse, Officier d’Academie, Licencie ^s Sciences, etc., and are
stated to contain : — Fleur de Neige, 29 per cent proteids and 22 per cent
carbohydrates ; Exquis, 24 per cent proteids and 36 per cent carbohydrates ;
Longuets, 15 per cent proteids and 64 per cent carbohydrates ; Madeleines,
6 per cent proteids, 52 per cent carbohy^drates, and 30 per cent fatty matters.
The Diabetiker, Madeleine, and Exquis biscuits are sweetened with sugar
substitutes, the other biscuits being unsweetened. All these preparations,
particularly those made in Germany, are pleasant to take, and may be
recommended w^here an absolutely starchless food is not considered essential.
IMessrs. Maurice & Co. selected these after a careful inspection of the various
foods in use at the continental spas. They themselves manufacture the
well-known “ Brusson Jeune ” gluten bread.

Digalen. — Several forms of this drug — ^tablets and solutions for oral or
, hypodermic administration — have been sent us by the Hoffmann-La Roche
Chemical Works Ltd. It is a sterile standardized solution of digitalis which
enjoys a considerable vogue on the Continent. Various advantages are
claimed for it over the ordinary preparations, and its virtues are at least
sufficient to recommend it for a wider use than it has attained up till now
in Britain. We should like to commend the neat little package in which
ampoules of solution for hypodermic injection are sent out.

Digesto-Laxative label! as (Sumner & Co., Liverpool) contain pepsin,
pancreatin, diastase, gentian, aromatics, and gr. extract of cascara in
each tablet — a combination which may be safely employed in many cases
of chronic functional dyspepsia. They are sugar-coated and chocolate-
flavoured.

Digitalin Tabloids, each containing gr. of the crystalline digitalin,
have been sent us by JMessrs. Burroughs, Wellcome & Co. Crystalline
digitalin is in frequent use as a cardiac tonic ; we are not convinced of its
superiority over fluid preparations of digitalis, though it is asserted that
it is less provocative of vomiting. The profession is timid in its use of
digitalis ; more harm is done by playing with it than by pushing it too far,
and w’e trust that the makers of these small tabloids wdll find that physicians
prescribe more than one or two per dose, as the label on the bottle suggests.

Digitalis Tincture, chemico-physiologically standardized, is sold by Mr.
W. Martindale, whose researches into the question of digitalis standardiza-
tion are well known, and this preparation embodies his belief in a chemical
method available for use in small laboratories. His work is fully described
in an interesting monograph on “Digitalis Assay,'" of which he has been
kind enough to send us a copy.

Elixir Acetomorph. et Terpin ; Elixir Heroin et Hyoscyam. (Reynolds &
Branson, Leeds) are pleasant preparations for the relief of irritable cough.

Elixir Pepto-Bismuthi Cone, — ^It is claimed by Messrs. Sumner Sc Co., of
Liverpool, that their preparation of these drugs is more effective than most

PHARMACY

728

MEDICAL ANNUAL

of its kind because of its acidity; the usual alkaline combinations, they
argue, require neutralization by the gastric hydrochloric acid before they
can become active. One drachm is equivalent to liquor bismuthi dr. i. tinct.
nucis vom. 5 min., acid, hydrocyan. dil. 2 min., morphinae hydrochlorid.
gr. pepsin gr. r. We find that prolonged keeping does not precipitate
the 'bismuth ; and like so many of this firm's products, it is an elegant
preparation.

Emetine, in highly soluble, non-irritating tablets of the hydrochloride
(gr. i in each) is prepared by Messrs. Oppenheimer. This drug has leaped
at one bound into the select group of specific remedies, thanks to the advocacy
of our esteemed contributor, Dr. Leonard Rogers, of Calcutta ; and we are
glad to find all the reliable firms ready to meet the demand for the drug
that is sure to arise in all lands where amoebic dysentery is rife.

Entiles. — These suppositories, made by Messrs. Burroughs, Wellcome 6 c
Co., surely need no further introduction. A new one — containing epinine,
a synthetic haemostatic similar to suprarenal extract — ^has been added to
the list. It is valuable in the treatment of rectal haemorrhage from various
causes. This firm has also favoured us with glycerine enules in a new packing,
which protects them from the air while leaving them easily accessible.

Formaldehyde Inhalant. — The revival of the inhalation treatment in
laryngeal and pulmonary tuberculosis and other affections of the respiratory
tract, by Dr. D. B. Lees, has been responsible for a series of inhalants, each
containing formalin in combination with various antiseptics and germicides.
The ease with which formalin abstracts oxygen from organic matter probably
accounts for its antiseptic efficiency ; and being non-poisonous, non-corrosive,
easy and clean in application, it is obviously an ideal antiseptic for internal
application. The series prepared by Messrs. Oppenheimer consists of four
inhalants suggested by Dr. C. Muthu, the author of “ Pulmonary Tubercu- ^
losis and Sanatorium Treatment." Inhalant A contains pine oil, menthol,
chloroform, etc., with formalin 2J, 5 or 10 per cent. Inhalant B contains
pine oil, menthol, chloroform, etc., with formalin 5 per cent and guaiacol
12^ per cent. Inhalant C contains pine oil, menthol, chloroform, etc., with
creosote 25 per cent, and terebene 12^ per cent. Inhalant D contains pine
oil, menthol, chloroform, etc., with guaiacol 25 per cent, tr. iodi 12} per cent,
terebene 12 J per cent, etc. The inhalation treatment of these may be
conducted by means of the Muthu formaldehyde inhaler, the aerizer, or
universal vaporizer. A prominent feature of this treatment is that it may
be continuously carried on wherever the patient is situated, a persistance
which is necessary in order to produce amelioration of such diseases. The
inhalants are issued in drop bottles each containing i oz.

Glycolactophos is one of the “ nerve-tonic " combinations of casein with
glycerophosphates for which these neurotic days appear to provide a ready
market. Messrs. Oay, Paget & Co., Ltd., of 71, Ebury Street, S.W., who
are the makers, are at any rate to be congratulated on their candour, for
the composition of their product is stated on the wrapper. It may he prepared
for ingestion in a variety of ways, and its taste is pleasant. The name of the
firm guarantees the genuineness of the product.

Glyphospher is a pleasant combination of glycerophosphates (calcium,
sodium, manganese, iron and strychnine) manufactured in Lyons and sold
in this country by M. Bresillon Sc Co., Carnage Buildings, Holborn, E.C.

Helalin et Pepsin Co., Liq. — ^This combination is a hepatic stimulant and
profceid digestive. It combines the antispasmodic, hepatic and sedative
effect of helalin, the active principle of Collinsonia Canadensis, with the
proteolytic power of a high-grade pepsin manufactured under the Webber
process, for which the manufacturers of this product have the sole European
rights. Obstinate cases of gonorrhoea, gleet, cystilis, etc., are said to have
yielded to its influence, owing to the sedative effect of helalin on the mucous

editor’s table

729

PHARMACY

membrane. In gastro-intestinal catarrh, renal and biliary colic, intestinal
indigestion and habitual constipation, excellent results are claimed. Issued
in Jib. Jib. or ilb. bottles, by Messrs. Oppenheimer, Son <& Co., London.

Hipposarcine Roy, a liquid extract containing all the soluble proteids of
the fresh muscle of the horse, claims to contain more protein, glycogen,-
haemoglobin and organic iron, and less fat, than beef-extracts ; in addition
to which the danger of tuberculous infection, so prevalent in oxen, is avoided
(surely rather a remote advantage). It is made* in France and sold in
England by M. Bre&illon & Co. Indications are anaemia, tuberculosis, etc.

lod^ol (Viel) is a colloidal iodine for injection in pulmonary affections,
hypertension, tuberculosis, chronic suppurations and so on. lodargol is
a "more concentrated form of the same, for gonococcal infections. It may
also be administered orally* in gelatine capsules, and locally in the same
way as tincture of iodine ; it is less irritating and more easily absorbed
than the latter. Various preparations have been sent to us by the British
agents, VieFs Electric Colloids Co., 118-122, Holborn, E.C., who will be
pleased to supply samples and literature to those interested.

Iodine Capsules (Mr. W. Martindale). — These consist of glass capsules
containing iodine, and encased in cotton wool and silk ; they are handy
for use as a first dressing for wounds. Various sizes are sold.

Kepler Malt Extract with Glycerophosphates (calcium, potassium, sodium
and magnesium) is now prepared by Messrs. Burroughs, Wellcome & Co.
The use of the excellent Kepler Extract enhances the value of this familiar
combination.

Kerol (QuibeU Bros., Ltd., Newark) is a diphenyl derivative, sent out in
three-minim gelatine capsules for internal administration as an intestinal
antiseptic. Several papers calling attention to the value of this drug have
already appeared in the journals, and we think it should commend itself to
the profession as deserving of investigation.

Lacteol (Dr. Boucard's) is a Parisian preparation of lactic ferment in tablet
form, sold by M. Br^sillon & Co, The method of manufacture is not described
in the literature we have received, but a wide list of clinical indications,
chiefiy gastro-intestinal, is given.

Lasophos is a new recruit to the apparently endless series of casein-glycero-
phosphate nerv^e tonic foods, prepared by the Medical Supply Association,
167-173, Gray's Inn Road, W.C. These compounds are useful under a
variety of conditions ; for instance, we have used them in convalescence
from the acute infections and during the course of enteric fever.

Lymphatic Gland Tabloids. — A writer who recently investigated the
incidence of enlarged tonsils and adenoids in children, states that in
such condition there is a leucocytosis, but with diminution of the lympho-
cytes. Theoretically, he considers that the tonsillar enlargement is an
attempt on the part of nature to increase the lymphoid tissue of the body.
Working on this theory, he adopted a treatment for such cases, consisting
of the administration of a preparation of lymphatic gland. He has applied
this treatment in a number of cases, with the result that the snoring has
been improved and the tonsils diminished in size. The dosage employed
was gr. 5, thrice daily, and no bad effects were observed. The preparation
used was that issued by Burroughs, Wellcome & Co. under the “ Tabloid "
Brand, each tabloid representing gr. 5 of fresh gland substance.

Morphine Hypophosphite. — Messrs. Burroughs, Wellcome & Co. have added
to their list “ Tabloid " Hypodermic Morplune Hypophosphite, in products
of four strengths. Morphine h3rpophosphite is a salt possessing qualities
which render it particularly suitable for use in hypodermic medication when
a concentrated solution* is desired. It is perfectly stable, is practically
neutral in reaction, and has the remarkable solubility of i in 3 of water.
In clinical use its great solubility is a point of value, and it has been found to

PHARMACY

730

MEDICAL ANNUAL

act well and promptly, without causing pain at the point of injection. The
gr. i and gr. J strengths are issued in tubes of 20. and the gr. J and gr. i
strengths in tubes of 12.

Omnopon is a preparation noticed by us in a previous issue. We call
attention to it once more because it deserves wider recognition in this country.
Sold on the Continent as “ pantopon,” it has gained considerable vogue. Ifc
contains all the alkaloids of opium, and may be given orally or hypodermically
wherever opium is indicated ; many of the drawbacks of opium and morphia
are avoided by its use. An interesting paper on its general employment
appeared in the Medical Press and Circular, SorgtembQv 17th. 1913. In
combination with scopolamine it may be used to induce narcosis for operations
or obstetrical work ; ampoules of this combination are issued in a very neat
package by the Hoffmann- La Roche Chemical Works Ltd., Idol Lane, E.C.

**OscoI'’ Tampons (Oppenheimer, Son & Co. Ltd.) consist of sterilized
cotton- wool impregnated vdth suprarenal principle (renaglan din), and inclosed
in a soluble gelatine capsule which renders it readily portable. It is destined
for use in various types of uterine haemorrhage. Boxes of six cost 4/--.

Ozoline (Messrs. Oppenheimer, Son & Co. Ltd.) is a soothing prophjdactic
cream containing an antiseptic and deodorant, which acts by the liberation of
nascent oxygen and the subsequent formation of innocuous compounds ;
it is destined for use as a dressing in obstetrics and general surgery.

Paracodin (Messrs. Knoll Sc Co. Ltd., London, E.C.) is a new codeia
preparation alluded to in the index of new remedies in the current volume.

Parofex, prepared by Messrs. Reynolds & Branson, of Leeds, is an excellent
form of paraffin for internal administration. It is pleasantly coloured and
flavoured, and is therefore particularly adapted for giving to children. Of
the virtues of paraffin in intestinal disorders associated with stasis it is
impossible to speak too highly, and this product may be recommended as
an admirable mode of administering it.

Perogen Bath Salts, sent out in packets, each of which supplies enough to
^deld one bath, are designed for the ready preparation of a nascent effervescing
oxygen, bath. For further information and literature, practitioners should
write to Messrs. A. & M. Zimmermann, 3, Lloyd's Avenue, E.C.

Petremol is another excellent liquid paraffin preparation sold by Messrs.
Oppenheimer, Son Sc Co. Ltd., who claim exceptional purity as one of its
chief virtues.

Phylacogens (Parke, Davis Sc Co.) are sterile aqueous solutions of modified
bacterial derivatives prepared according to the process of Dr. A. A. Schafer,
of California. There are five distinct varieties, viz., mixed infection,
erysipelas, gonorrhoea, pneumonia and rheumatism phylacogens.

The mixed infection phylacogen is a polyvalent preparation obtained by
the culture, in approximately equal proportions, of a wide variety of pathogenic
bacteria, such as the several staphylococci, streptococcus pyogenes, hacillus
pyocyaneus, bacillus diphtherice, diplococcus pneumonia, bacillus typhosus,
hacillus coli communis, streptococcus rheumaficus and streptococcus erysipelatis ,
numerous strains of each organism being employed. Mixed infection
phydacogen also forms the basis of the other varieties, being modified by the
addition of a predominating proportion of metabolic substances obtained
from the culture of the organism considered to be paramount in the
pathological condition for which the respective phylacogen is to be used.
It is Dr. Schafer’s belief that the symptoms developed during the course of
an infectious disease are due, not only to the effects of a single species of
organism (the specific infection), but to the influence of other organisms
which must be taken into account in any mode of treatment which is to be
successful.

The phylacogens are administered subcutaneously or intravenously. We
ha\"e had some little personal experience of the phylacogens, but hesitate to
pronounce any^ opinion. It is obvious that so sweeping a generalization as

editor's table

731

PHARMACY

that on which this new therapeutic venture is based calls for careful and
prolonged testing before it can receive general acceptance. No doubt this
testing will be applied, and the published reports (which are already
numerous) will be available for the profession to form an opinion upon.

Pini Sed., Ung. — A new antipruritic ointment by Reynolds & Branson,
of Leeds. One advantage is its freedom from grittiness — a fault we have
noted in one or two ointments of this class.

Pneumosan is a drug which is offered by the Pneumosan Chemische Fabrik,
132, Great Portland Street, W., as a remedy for pulmonary and other forms
of tuberculosis. It is a combination of methylene blue, valeric acid, and
codeine, which is said to act by destroying the bacilli. It is administered by
intramuscular injection. Several British clinicians have reported favourably
as to its value. Our own experience is at present limited to one advanced
case ; here undoubted though temporary benefit followed its administration.
The fact that it is administered by intramuscular injection militates against
a wide application, as patients are apt to object to it, however painless it may
be. However, we hope to have opportunity for a thorough test of this remedy.

Polylactol (The Bayer Co., 19, St. Dunstan’s Hill, E.C.) is destined for use
as a galactagogue, a purpose it is said to have realized with gratifying success.
It is a compound of somatose, organic iron, maltose, and galactose. A 3/-
bottle lasts ten days to a fortnight, so it is not a costly remedy.

Propaesin is a new local anaesthetic, sold by B. Kuhn & Co., i 5 . Rood
Lane, E.C. Chemically it is a para-amido-benzoic acid propyl-ester. It has
been carefully tested, and appears to be innocuous. The rapid' action, even
in small quantity, on the mucous surface of the tongue, is remarkable. It
may be applied to a painful stomatitis in the form of pastilles, or as an oint-
ment to painful ulcerations of the skin. Other applications will no doubt
suggest themselves to the practitioner, who will, we think, find this substance
worthy of notice. The manufacturers supply literature explaining the
pharmacology of the drug.

Pulverettes. — By a really admirable device Messrs. Oppenheimer have
enclosed powders in a frail chocolate and sugar shell which dissolves in the
mouth. It is so light that it can be crushed between finger and thumb. The
disadvantages inherent in pill and tablet medications are thus avoided to a
great extent. Many drugs have been put up for administration in this way,
and the makers are prepared to embody the practitioner’s private formulae
in the same vehicle.

Roboleine (also an Oppenheimer product) is composed of red bone-marrow,
cream of malt, and h>q)ophosphites. It may be taken “ neat ” or with milk or
other foods, and affords an efficient and palatable substitute for cod liver oil.

Sapokrol (Messrs. Reynolds & Branson, Leeds), a germicide, disinfectant
and antiseptic, is a saponified solution of meta- and other cresols, which are
more active and less caustic antiseptics than phenol. Sapokrol does not
coagulate albumin nor corrode instruments, forming a clear solution, on
dilution, with hot or cold w^ater, in any proportions. A pathologist reports
that “ a I per cent solution with distilled water kills a very active emulsion
of t3q)hoid bacilli in 2J minutes.” Owing to the solvent action of Sapokrol
on mucus, etc., it is particularly useful as a cleansing agent for sputum flasks,
etc. Directions for use : — For general disinfecting purposes, one tablespoon-
ful to one pint of water — approximately 3 per cent solution. For disinfecting
the hands or instruments, one dessertspoonful to one pint of water —
approximately ij per cent solution. For douching or irrigation purposes,
and for the treatment of w'ounds, one teaspoonful to one pint of water —
about I per cent solution. An aluminium measure marked in teaspoons is
supplied with each bottle^

Scarlet Red Ointments have come to stay. We welcome two new brands,
the “ Ung. Bietrich ” (5 per cent) of Messrs. Oppenheimer, and Messrs.

PHARMACY

732

MEDICAL ANNUAL

Sumner & Co/s 10 per cent scarlet red with erytheinol ointment. This
latter provides an excellent base for the scarlet red, and the combination is
a reasonable one.

Secacosnln is a sterile ergot extract, which seeks to embody all the active
principles while eliminating the harmful constituents. It is physiologically
standardized, and being sterile, may be used for injections as well as for
oral administration. (Hoffmann-La Roche Chemical Works, Ltd.)

Sennax (Knoll & Co.) contains the water-soluble glucoside of senna leaves,
isolated from the crude drug by a patented process. A reliable product,
sent out in powder, solution, or tablet form.

Thigenol (Hoffmann-La Roche Chemical Works, Ltd.) is a sulpho-oleate
containing 2-S per cent of organically fixed sulphur. It is a dark brown
syrupy liquid, almost odourless, which does not permanently stain linen.
In skin diseases it may be applied to relieve irritation ; it forms, when dry,
a non-adhesive covering on the skin. The makers have sent us a pleasant
soap containing ib per cent of this compound.

Thiocol, from the same firm, is a guaiacol compound put up in powder form,
in a syrup, and in tablets. The indications for its use are those of guaiacol.

Thyroidecto raised Horse Serum (Parke, Davis & Co.) — This serum, from
the blood of horses which have been deprived of the th^Toid gland, is
administered in cases of exophthalmic goitre, on the assumption that it is
rich in substances which in normal animals combine with thyroid secretion
in the blood and prevent the occurrence of thyroid intoxication. It may be
given orally in doses of from i to 5 c.c. every two or three days, or from 0-5
to I c.c. may be injected subcutaneously.

Tuberculins. — There is no need to say more about the purchase of tuber-
culin for therapeutic purposes than that any form of this medicament can
be procured in any dose from any of the principal firms. Among
“ appliances ” we have noticed a syringe for administration of tuberculin,
made by Messrs. Burroughs, Wellcome & Co. The same firm have sent us
particulars of a “ tabloid ” tuberculin dilution outfit. From their account
we learn that the whole equipment packs into an aluminized case measuring
8| by aj by 5§ inches ; in spite of these modest dimensions, the outfit is
evidently easy to manage accurately^ Messrs. Sumner, of Liverpool, have
favoured us with a neat little outfit, with full directions, for carrying out a
quantitative tuberculin diagnostic inoculation, the reaction to which yields
information of prognostic as well as diagnostic value (see paper by' Dr. E. C.
Morland, Lancet, 19x2, volume ii., page 68).

Tylcalsin and Tyllithin, names dimly' reminiscent of the “ !^lue Bird,”
emanate from Mr. W. Martindale. They are soluble aceto-salicylates of
calcium and lithium respectively, and may be used for easing the various
pains to which the term “ rheumatic ” is applied.

Vaccines. — Messrs. Parke, Davis & Co. inform us that they have added to
their list of “ stock ” preparations vaccines for treatment of actinomy'cosis,
malta fever, ty'phoid fever, and the all too common cold. The list of
organisms included in this latter contains seven distinct varieties. We
are also reminded that Mr. W. Martindale represents the Wimpole Institute
in the sale of vaccines, and that this institute makes a special feature of
sensitized vaccines, an account of w’hich appears in the first part of this
volume.

Yellow Oxide of Mercury Ointment (Parke, Davis & Co.) is specially suitable
for ocular medication, being prepared from freshly-precipitated yellow
mercuric oxide by a process winch produces an ointment that is perfectly
free from grittiness. The small tubes of pure tin in which the ointment is
supplied are very' convenient for the patient’s use^ they' are furnished with
elongated nozzles which facilitate the introduction of a small quantity of the
ointment on to the inner surface of the everted eyelid.

BOOKS OF THE YEAR.

A List of the Principal Medical Works and New Editions
Published during 1913.

For the convenience of our ?vatiers any o/ the ‘toorks in this list can be obtained
from Messrs* John Wright Sons Ltd.^ "“Medical Annual" 0_ffices^ Bristol.

AMBULANCE AND NURSING.

Anatomy for Nurses. By E. M. Bundy. 2nd ed. 215 Ulus. ChtmhiU

Net 75. 6d .

Anatomy and Physiology for Nurses. By Le Roy Lewis. - 3rd ed.
Saunders ------- Net 8s.

Applied Bacteriology for Nurses. By C. F. Bolduan and M. Griind.

Saunders - - - - - - - Net 6s.

Bandaging Made Easy. By M. R. Hosking. i6mo, pp. no. Scienifiic
Press - - - ■ - - - - Limp, Net is.

British Red Cross Society’s First Aid Manual. By James Cantlie.
No. I. 2nd ed. Cassell ----- Net is.

Compendium of Aids to First Aid. By N. Corbet Fletcher. With an
Introduction by James Cantlie. Bale - - - 6d .

Course of Lectures on Medicine to Nurses. By Herbert E. Cuff,
6th ed. Cr. 8vo, pp. 292. Churchill - - - Net 3s. 6d .

Elementary Clinical Pathology for Nurses. By Geo. Herschell and
R. Weiss. 2nd ed. Churchill - - - - Net is.

Explanatory Lectures for Nurses and their Teachers. By H.
Hawkins-Dempster. Illustrated by Coloured Plate and numerous Illustra-
tions in the text. Demy 8vo, 240 pp. ]. Wright & Sons Ltd . Net 3s. 6d .
** First Aid ” to the Injured and Sick. By F. J. Warwick and A. C.
Tunstall. An Ambulance Handbook. 8th ed', revised. 121110, pp. 262.
J , Wright & Sons Lid . _ _ - - Boards , Net is .

History of Nursing, A. Edited by L. L. Dock. Vols. III. and IV. 8vo.

Putnam - - - ' - . . - Net 21s.

How to Succeed as a Trained Nurse. By Sir Henry Burdett. Cr. 8vo,
pp. 200. Scientific Press ----- Net 2s . 6d ,

The Indian Manual of First Aid. By R. J. Blackhani. i8mo. Thacker

Boards , Net is . 6d .

Invalid and Convalescent Cookery. By Mary E. Birt. 2nd ed. i6mo.

J . Wright (Sr Sons Lid . - . - - Sewed , Net 6d .

Manual of Ambulance. By J. Scott Riddell. 6th ed. Cr. 8vo, pp. 270.
C . Griffin ------- Net 6s.

Manual for Women’s Voluntary Aid Detach.ments. By P. C. Gabbett.
2nd ed., revised and enlarged. i6mo, pp. 116. /. Wright S * Sons Ltd .

Limp , Net is *

Maternity Nursing. By Sarah Macdonald. Cr. 8vo, pp. 216. Methuen *

Net 3s. 6d *

Medicine for Nurses and Housemothers, By G. H. Hoxie and Pearl
Laptad. 2nd ed. Saunders _ _ - - Net 6s. 6d .

Nurse’s Duties Before and During Operations. By E. Margaret Fox.

i6nio. Scientific Press - _ - - • Limp , Net is *

Nursery Notes for Mothers. By C. Willett Cunnington. Cr. 8vo.
Pp. 148. Bailliere - - - - - . - 2S. 6d *

MEDICAL ANNUAL

BOOKS 734

Nursing of Nervous Patients. By Edwin L. Ash. Cr. 8vo, pp. 122.
Scientific Press ------ Piet 25. 6 d,

Obstetric and Gynecologic Nursing. By E. P. Davis. 4th ed. Saunders

Net 8s.

Obstetrics for Nurses. By J. B. Dc Lee. 4th ed. Saunders Net 12s.
Pathology and Bacteriology for Nurses. By Jay G. Roberts. Saunders

Net 6s.

Plan of Clearing Hospital, ioo Beds, with Complete Inventory.
Arranged for the Guidance of Voluntary Aid Detachments. i2mo.
Simp km - - - - - - . Sewed, Net 6d,

Practical Nursing. By Isla Stewart and H. E. Cuff. 4th ed., thoroughly
revised and enlarged. Cr. 8vo, pp. 458. W. Blackwood - Net 5s.
Private Duty Nursing. By K. de Witt. Cr. 8vo. Lippincott. Net 5s.
Problems in First Aid. By L. M. F. Christian and W. R. Edwards.

i6mo, pp. 176. St. John Ambulance Assoc. ^ Limp, Net 6d.

Short Practice of Midwifery for Nurses. By Henry Jellett. 4th ed.,
revised. 6 Plates, i6g Ulus. Cr. 8vo, pp. 524. Churchill Net ys. 6d.
Volunt.\ry Aid Detachments in Campaign. By C. R. S. Bradley. i2mo,
Bailliere - - - - - - - Net is. 6d.

ANATOMY AND PHYSIOLOOY.

Anatomical Charts. By — Piersol. Set of 50. 12s. 6d. per Chart for set.

Anatomy, Descriptive and Applied. By Henry Gray. i8th ed. Edited
by Robert Howden. Ulus. Roy. 8vo, pp. 1328. Longmans Net 32s.

Anatomy and Physiology of the Fifth Cranial or Trigeminal Nerve
AND OF ITS Ganglia and Connections. By L. H. Pegler. Chart printed
in colours, mounted on roller, 48in. by 6oin. Net 21s. ; In cloth cover,
mounted on linen, with text. Bailliere - - - Net 25s.

Comparative Anatomy of Vertebrates. By J. S. Kingsley. Ulus.
Demy 8vo. /. Murray ----- 'Net 12s.

Companion to Manuals of Practical Anatomy. By E. B. Jamieson.
i2mo, pp. 552. Frowde ----- Net 6s.

Course in Normal Histology. By Rudolf Krause. A Guide for Practical
Instruction in Histology and Microscopic Anatomy. Only authorized
Translation, by P. J. R. Schmahl. In two parts. 98 Coloured Plates and
30 Ulus. Imp. Svo. Heinemann Part /, Net 55. / Part II, 2$$.

Cunningham’s Text Book of Anatomy. Edited by Arthur Robinson.
4th ed., enlarged and rewritten. Roy. Svo, pp. 1622. H. Frowde.

Net 3 IS. 6d.

Handbook of Physiology. By W. D. Halliburton, nth ed. Cr. Svo,
pp. 944. /. Murray ----- Net 15s.

Histological Studies on the Localization of Cerebral Function.
By Alfred W. Campbell. Medium 4to. With 29 Plates and 23 Text-
figures. Cambridge Umversiiy Press - - - Net 185.

Human Body, Its Muscles, its Organs, its Skeleton. Svo. Ewart,
Seymour ------- Net is. 6d.

Human Embryology and Morphology. By Arthur Keith. 3rd ed.,'
revised and enlarged. Demy Svo, pp. 484. 442 Ulus. E. Arnold. Net 15s.

Human Physiology, By Luigi Luciani. Vol. 11 . Ulus. Demy Svo,
pp. 566. Macmillan ----- Net 185.

Introduction to Biology. By M. A. and A. N. Bigelow. Cr. Svo. Mac-
millan - - - - - - - -6s.

Manual of Anatomy. By A. M. Buchanan. New ed. Svo. i Vol.
Bailliere - Complete, Net 21s. ; Vols. I. and II., each. Net 12s. 6d.

Normal Histology. By — Piersol. loth ed. Svo. Lippincott

Cloth, Net 15s.

Pocket Anatomy. 7th ed,, revised and Edited by C. H. Fagge. i2mo.
pp* 312* Bailliere ------ Net 3s. 6d.

BOOKS

MEDICAL ANNUAL 735

Problems of Life and Reproduction. By Marcus Hartog. Illus. Demy
Svo. /. Murray ------ ys. 6 d.

Text-book of Anatomy. By D. J Cunningham. 4th ed. H. Frowde

Net 315. 6 d.

Text-book of Biology. By W. M. Smallwood. Roy. Svo. pp. 285.

13 Coloured Plates and 243 Illus. BaillUre - - Net los. 6 d.^

Text-book of Physiology. By Isaac Ott. 4th ed., revised and enlarged.
Svo. S. Phillips ------ Net 14s. 6 d.

Text-book of Physiology. By W. H. Howell. 5th ed. Saunders

Net iSs.

Vertebrate Embryology. By J. \V. Jenkinson. Comprising the Early
History of the Embryo and its Foetal Membranes. Demy Svo, pp. 26S.
H. Frowde ------- Net 125. 6 d,

The Vertebrate Skeleton. By S. .H. Reynolds. 2nd ed. Demy Svo.
144 Illus. Cambridge University Press - - - Net 155.

BACTERIOLOGY.

Abel’s Laboratory Handbook of Bacteriology, 2nd English ed.,
pp. 264. H, Frowde ----- Net 5s.

Bacteria. By — Schottelius. 2nd ed. H. Frowde- - Net Ss. 6 d.
Bacteriology, Part II. 2nd ed. Catechism Series. Cr. Svo, pp. 84.
Livingstone ------ Sewed, Net is.

Bacteriology of Diphtheria. By Various Writers. Reissue, with
Supplementary Bibliography. Roy. Svo. Cambridge University Press

Net 155.

CoMPEND ON Bacteriology, including Animal Parasites. By Robert L.
Pitfield. 2nd ed. With 4 Plates and 85 other Illus. Cr. Svo, pp. 286.
Oxford University Press ----- Net $s.

Diagnosis of Bacteria and Blood-Parasites. By E. P. Minett. and
ed. i2mo, pp. 88. BaillUre - - - - Net 2 s. 6 d.

Elementary Bacteriology and Protozoology. By H. Fox. Cr. Svo.

5 Coloured Plates and 67 Illus. Churchill - - - Net 6 s. 6 d.

Elements of Bacteriological Technique. By J. W. H. Eyre. 2nd ed.
Saunders ------- Net 13s.

Household Bacteriology* By E. D, and R. E. Buchanan. For Students
in Domestic Science. Cr. Svo. Macmillan - - Net 10s.

Laboratory Guide to Parasitology. By W. B. Herms. Svo. Mac-
millan ------- Net 3s. 6 d.

Manual of Bacteriology. By Robert Muir and James Ritchie. 6th ed.
Cr. Svo, pp. 760. Frowde ----- Net los. 6 d.

Medical Bacteriology and Protozoology. Part I. 2nd ed., enlarged
and revised. Catechism Series. Cr. Svo, pp. 82. Livingstone

Sewed, Net is.

Practical Bacteriology, Blood Work and Animal Parasitology.
By E. R. Stitt. 3rd ed., revised and enlarged. 4 Plates and 106 Illus.
Cr. Svo, pp. 426. H. K. Lewis - - - - Net 6 s. 6 d.

Practical Bacteriology, Microbiology, and Serum Therapy : Medical
and Veterinary. By A. Besson. A Text-book for Laboratory Use,
Roy. Svo, pp. 922. Longmans - - - - Net 36s.

Vaccine and Serum Therapy. By E. H. Schoror. 2nd revised ed. Roy.
Svo, pp. 316. Illus. Kimpton - - - - Net 12s. 6 d,

CANCER.

Cancer of the Breast. By C. B. Lockwood. An Experience of a Series
of Operations and their Results. Demy 8vo, pp. 234. Oxford University
Press ------ Cloth, Net los. 6 d.

Cancer, its Cause and Treatment without Operation. By Robert
Bell. 2nd ed., revised. Cr. Svo, pp. 336. Bell - - Net 55.

BOOKS

736

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Cancer Hospital Research Institute. Vol. I. — Selected Papers. Edited
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Cancer : The Problem of its Genesis and Treatment. By F. W. Forbes
Ross. Demy 8 vo. Methuen, - - - . Net 55.

Cancer of the Rectum, its Surgical Treatment. By H. Cripps. 6th
‘ ed. Svo. Chuf chill - - - - - Net

Researches into Induced Cell-reproduction and Cancer and other
Papers. By H. C. Ross and Others. Vol. III. Demy Svo. Ulus.'
J. Murray - - - - - - - Net ^s.

Studies in Cancer and Allied Subjects. Vols. I and III. 4to. H ,
Frowde Each, Net, 21s,

CHEMISTRY AND PHYSICS.

The Chemical Constitution of the Proteins. By R. H. A. Plimmer.

Part 3. 2nd ed., refused. Roy. Svo. Longmans - - Net 3s. 6d.

Dictionary of Applied Chemistry. By Sir Edward Thorpe. Vol. IV.
— Oilstone-Soda Nitre. Revised and enlarged ed. Ulus. Roy. Svo.
Longmans ------- Net 455.

General Chemistry Laboratory Manual. By J. C. Blake. Svo.
Macmillan ------- Net 8s,

Manual of Clinical Chemistry, Microscopy, and Bacteriology. By
M. Klopstock and A. Kowakski. 2nd ed. Demy Svo, pp. 371. 16

Coloured Plates and 43 Ulus. Heinemami - - Cloth, 12s. 6d.

Manual of Pharmacology. By Walter E. Dixon. 3rd ed., revised.
Ulus. Demy Svo, pp. 464. E. Arnold - - - Net 15s.

Organic Chemistry for Students of Medicine. By James Walker.

Demy Svo, pp. 340. Gurney 6* Jackson - - - Net 6s,

Practical Chemistry. By J. C. Brown. 6th ed. Edited by G. D.

Bengough. Svo. Churchill-. - - _ - Net 2s, 6d,

Practical Physiological Chemistry. By Sydney W. Cole. Cr. Svo,
pp. 242. W, Heffer ----- Net ys. 6d.

Qualitative Analysis of Medicinal Preparations. By H. C. Fuller.

Cr. Svo. Chapman &• Hall _ - - - Net 6s. 6d.

Refraction and Dispersion of the Halogens, Halogen Acids, Ozone,
Steam, Oxides of Nitrogen and Ammonia (Royal Society). By C.
and M. Cuthbertson. 4to, pp. 26. Dulaii - Sewed, Net is, 6d.

CHILDREN’S DISEASES AND INFANCY.

Babies. By Margaret French. A Book for Maternity Nurses. 1 21110,
pp. 88. Macmillan- - - - - Limp, Net is,

Birch’s Management and Medical Treatment of Children in India.

5th ed. Cr. Svo. Thacker _ - - _ Net 10s. 6d.

Book for Mothers on the Management of Children in Health and
Disease. By A. M. Usher. Cr. Svo, pp. 118. Churchill Sewed, Net is.
Care* of Children. By R. J, Blackham. Practical Hints for Mothers
and Nurses at Home and Abroad. 3rd ed. Cr. Svo, pp. 114. Scientific
Press ------ Boards, Net is, 6d.

Care and Feeding of Children. By L. E. Holt. 6th ed. Appleton

Net 25 .

Diseases^ of Children. By Jolm McCaw. A Manual for Students and
Practitioners. Cr. Svo, pp. 536* 14 Plates and Ulus. Bailliere

Net 105 . 6d,

Diseases of Children. , By Sir James Frederic Goodhart. loth ed.
Edited and revised by George Frederick Still. Demy Svo, pp. 976. Churchill

Net 16s,

Diseases of Children. By H. E. Tuley. 2nd revised ed. Roy. Svo.
3 Coloured Plates, 106 Engravings. Kimpton - - Net 245.

MEDICAL ANNUAL

737

BOOKS

Diseases of Children. By Various Authors. Edited bv Archibald E.

Garrod. Fully Ulus. Pp. 1200. E. Arnold - " - Ket 305.

Feeding and Care of Baby. By F. Trub^’ King. Svo. Macmillan

Sewed, Nei is.

Hygiene of the Nursery. By Louis Starr. 8th ed., with 26 Ulus. Cr.

Svo, pp. 342. H. K. Lewis - - _ - 3s. 6d.

Infant Care and Management. By Edith L. Maynard. Cr. Svo, pp.
122. E. Arnold ------ 15.

Lectures on Diseases of Children. By Robert Hutchison. 3rd ed.,
enlarged. Demy Svo, pp. 416. E. Arnold - - Net 10s. 6d.

The Nutrition of the Infant. By Ralph Vincent. 4th ed. Demy Svo,
pp. 362. Coloured Plate and 57 Ulus., including 26 Micro-photographs.
BaillUre ------- ]S!ei los. 6d.

Orthopedics in Medical Practice. .By A. Lorenz and A. Saxl. Demy
Svo, pp. 300. 39 Ulus. Bale - - . - ]^et 7s. 6d.

Treatment of Disease in Children. By G. A. Sutherland. 2nd ed.
Demy Svo, pp. 404. H. Frowde - - - - Net los. 6d.

DENTISTRY.

Anatomy and Histology of the Mouth and Teeth. By I. N. Bromell.

4th ed., revised. Roy, Svo. H. Kimpion - - - Nei 12s. 6d.

Dental An.esthetics. By Wilfred E. Alderson. 2nd ed. i2mo, pp. 116.

J. Wright & Sons Lid. ----- ^ei 35.
Dental Examination Papers. Livingstone - - - Net is.

Dental Jurisprudence. By W. E. Mikell, Demy Svo, pp. 570. Kimpton

Net i2S, 6d.

Dental Materia Medic a and Therapeutics. By H. Prinz. 3rd ed.

Roy. Svo, pp. 595. 103 Engravings. Kimpton - - Net 15s.

Introduction to Dental Anatomy and Physiology, Descriptive and
Applied. By Arthur Hopewell-Smith, 334 Ulus. Roy. 4to, pp. 372.
Churchill ------- Net 185.

Lecture Notes on Chemistry for Dental Students. By H. C. Smith.

Revised ed. Svo. Chapman S> Hall - - - Net los. 6d,

Porcelain Filling of Teeth. By H. J. Mamlock. Svo. 173 Ulus.

From 2nd German edition. Bailliire - - - Net 45.

Surgery for Dental Students. By G. P. Mills and H. Humphreys.

50 Ulus. Demy Svo, pp. 352. E, Arnold- - - Net 12s. ^d.

Text-book of Dental Pathology and Therapeutics. By H. H. Burchard,
For Students and Practitioners. 4th ed., revised. Ro3^ Svo, pp. 750,
575 Engravings and Coloured Plate. Kimpton - Cloth, Net 2ss.
Text-book of Prosthetic Dentistry. Edited by C, R, Turner. 4th ed.
Revised and greatly enlarged. Roy. Svo, pp. 856, with 900 Engravings.
Kimpton ------- Net 26s.

EAR, THROAT, AND NOSE.

Accessory Sinuses of the Nose. By R. H. Skillern. Svo. Lippincott

Cloth, Net 1 8s.

Diseases of the Ear. By — Keriison. Svo. Lippincott

Cloth, Net 2 IS.

Diseases of the Mouth. By. F. Zinsser. 4to, pp. 269. 52 Coloured
Plates and 21 Illus. Rehman - - - - Net 30s.

Ear Troubles : Their Symptoms and Their Cure. By H. W. Slauson.

i2mo. Harper - - - ' - - - Het is.

Effects of Stimulation and Extirpation of the Labyrinth of the
Ear, and their Relation to the Motor System. By J. G, Wilson and
F. H. Pilte. Part i — ^Experimental. 4to, pp. 33. Bulau

Sewed, Net 2s. 6d.

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Etiology of Endemic Goitre. By R. McCarrison. 8vo. Bale

Net I os. 6d.

The Labyrinth. By A. Braun and I. Friesner. An Aid to the Study of
Inflammations of the Internal Ear. Imp. 8vo, pp. 250. 32 Plates and

50 Ulus. Heivemann - - - - - 17s. 6d.

Nose, Throat, and Ear. By — Packard. 2nd ed. Svo. IJppincoit

Clnth, Net 15s.

Practical Guide to Diseases of the Throat, Nose and Ear. By William
Lamb. 3rd ed. Cr. Svo, pp. 368. 57 Illus. Baillieve ~ Net ys. 6d.

Text-book of Diseases of the Nose, Throat and Ear. By F. R. Packard.
2nd ed. Svo. LippincoU ----- Net 15s.

ELECTRICITY, RADIO-THERAPY, AND PHYSICAL METHODS.

Carbon Dioxide Snow : Its Therapeutic Uses, Methods of Collection,
AND Application, By J. Hall-Edwards. Cr. Svo, pp. 94. Simpkin. 3,5. Cm.
Electro-Therapeutics for Practitioners. B y Francis Howard Huinphris.

Illus, Demy Svo, pp. 250. E. Arnold - - - Net Ss. 6d.

Interpretation of Radium. By Frederick Soddy. 3rd cd., revised and
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Tonic Medication. ' By H. Lewis Jones. The Principles of the Method
and an Account of the Clinical Results obtained. Cr. Svo, pp. 160. H. K.
Letvis Net 5s.

Lectures on Medical Electricity to Nurses. By J. Delpratt Harris.

Cr. Svo, pp. 98. 23 Illus. H. K. Lewis - - - Net 2s. Cd

Manual of .v-Ray Technique. By — Christie. Svo. LippincoU

Cloth, Net 6s.

Massage : Its Principles and Practice. By Max Bohm and C. F. Painter.
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Massage : jManual Treatment, Remedial Movements. By D. Graham.

4th ed., revised. Svo. LippincoU - - - - Net 11s.

Medical Electricity, By H. Lewis Jones. A Practical Handbook for
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. Net I2i'. 6d.

Medical Electricity and Light. By Ettie Sayer. An Elementary Text-
book for Nurses. Cr. Svo, pp. 136. Illus. Scientific Press. Net 3s. 6d.
Natural Therapy. By Thomas D. Luke and Norman Hay Forbes. A
IManual of Physio-Therapeutics and Climatology. Illus. New cd. Demy
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Radium, as Employed in the Treatment of Cancer, Angiomata, Keloids,
Local Tuberculosis, and other Affections. By Louis Wickham and
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Radium, its Physics and Therapeutics. By D. Turner. 2nd ed., revised
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Radiuji Therapeutics. By N. S. Finzi, H. Frowde - - Net 6s.

Resuscitation from Electric Shock, etc. By C. A. Lauffer. i2mo.
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Text-book of Massage and Swedish Gymnastics and other Exercises
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Scientific Press - - - « . _ 2s. 6d.

X-RAY Diagnosis and Treatment. By W. J. S. Bytliell and A. E. Barclay.
H. Frowde ------- ]<yet 15s.

EYE.

All About Sight Tests: Board of Trade Regulations. By D. H.

Bernard. Cr. Svo, pp. 40, boards. J. Brown - - Net is.

AjMERICAN ENCYCLOP.aEDIA AND DICTIONARY OF OPHTHALMOLOGY. Edited
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Cases of Accident to Shipping and on Railways due to Defects of
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Defective Ocular Movements and their Diagnosis. By — Landolt.
H. Frowde ------ I Os.

Diseases of the Eye. By G. E. de Schweinitz. yth. ed. Saunders

Net 2 IS.

Diseases and Injuries of the Eye. By William George Sym. Cr. Svo,
pp. 510. Black - - - - - - Net ys. 6d,

Disturbances of the Visual Functions. By Prof. W. Lohmann. Trans-
lated by Angus MacNab. 39 Ulus. Roy. Svo, pp. 185. Bale Neti^s.
Elementary Physical Optics. By W. E. Cross. Cr. Svo, pp. 312. H.

Frowde - - - - - - - 3s. 6d.

Guide to the Microscopic Examination of the Eye. By P. Greeff and
Others. 4to. G. Putnam ----- Net ys. 6d.

Modern Ophthalmology. By J. M. Ball. 3rd ed., revised and enlarged.

Roy. Svo. 5 . Phillips - - - - - Net ^\s. 6d.

Ophth.\lmic Di.^gnosis. By Charles H. Beard. Illus. Heinemann £i'is.
Ophthalmic Semeiology and Diagnosis. By C. H. Beard. " Svo.
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Ophthalmic Surgery. By J. Mellar. Edited by W. M. Sweet. 2nd. ed,
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Pathology of the Eye. By — Adams. H. Frowde - Net 5s.
Researches in Magneto-Optics. By P. Zeeman. With Special Reference
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Sclero-Corneal Trephining in the Operative Treatment of Glaucoma.

By R. H. Elliot. Svo. G. Putnam - - . Net ys. 6d.

Surgery of the Eye. By E. Torok and G. H. Grout. Svo, pp. 508.

2 Coloured Plates and 509 Illus. BaillUre • - Net x8s.

Text-book of Ophthalmology in the Form of Clinical Lectures. By
F. Roemer. Vols. II. and III. Roy. Svo. Heinemann. Each, Net 10s. 6d.
Trachoma and its Complications in Egypt. By A. F. MacCallan. Demy
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FEVERS AND SPECIFIC INFECTIONS.

Administrative Control of Small-pox. By W. McC. Wanklyn. Svo.
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Dysenteries, their Differentiation and Treatment. By Leonard
Rogers. Oxford Medical Publicaiions. Demy Svo, pp. 348. Oxford
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Epidemic Cerebrospinal Meningitis. By A. Sophian. Roy. Svo, pp.
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Epidemic Infantile Par.a.lysis (Heine-Medin Disease) . By Prof. Paul FI.
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Essentials of Fever Nursing. By Lytton Maitland. i6mo, pp. 116.

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How TO Diagnose Small-pox. By W. McC. Wanklyn. A Guide for General
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Immunity" in Infective Diseases. By EHe Metchnikod. Translated by
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Influenza, its History, Nature, Cause, and Treatment. By Arthur F,
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Introduction to the Study of Infection and Immunity. By C. E.
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IMalaria : Cause and Control. By W. B. Herms. Svo. Macmillan

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Malaria : Etiology, Pathology, Diagnosis, Prophylaxis, and Treat-
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Manual of Tropical Medicine. By Aldo Castellani and A. J. Chalmers.
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Meningococcus Meningitis. By H. Heinian and Feldstein. Svo. Lippin-
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BOOKS

750

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Surgery of the Vascular System. By B. M. Bernheim. Svo. Lippincott

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Treatment of Hemorrhoids and Rectal Prolapse by means of
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URINARY DISEASES,

Diabetes: Its Pathological Physiology. By John J. R. Macleod.
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The Practice of Urology. By C. H. Chetwoocl. Roy. Svo, pp. S24.
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MEDICAL ANNUAL 75 1

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Our Outsides, and What they Betoken. By W. T. Fernie. Cv. Svo,
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Physician in English History. By Norman Moore. Linacre Lecture,
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752

MEDICAL INSTITUTIONS, HOMES, SPAS, Etc.

we are very anxious to make this list complete, and to give all necessary information ;
but unless our circular of enquiry— wA/cA in every case is stamped for reply— \% promptly
returned, we cannot undertake, the responsibility of inserting particulars of an Establish-
ment which may have been closed.

INSTITUTIONS, HOSPITALS, AND LICENSED HOUSES FOR THE

TREATMENT OF

Abex*deen, — Aberdeen City Mental
Hospital. Res. Med. Supt., H. de
M. Alexander, M.D. Access — ^New-
machar station, i-]- miles.

Royal Asylum.. Res. Med. Supt.,
Wm. Reid, M.D.; Sec., A. S.
Finnic, 343, Union Street. Access
— Aberdeen station, i mile.
Abergavenny. — M onmouthshire
Asylum. Res. Med. Snpt., N. R.
Phillips, M.D. Access— G.W.R.
station, mile ; L. Sc N.W. f- mile.
Alton (Hants). — Westhrooke House.
Res. jNIed. Supt., J. F. Briscoe,
M.R.C.S. Access — Alton station,
J mile.

Argyll and Bute. — District Asylum,
Lochgilphead. Res. Med. Supt.,
C. J. Shaw, M.D. Access — Rail
to Gourock, thence by steamer to
Ardrishaig, 2J miles distant.
Armagh. — District Asylum. Res.
Meet. Supt., Dr. Geo. R. Lawless.
Access — Armagh, J mile.

The Retreat, Armagh. — Res. Med.
Supt., Dr. J. Gower Allen, J.P.
Access — Richhill station, i J miles,
or Armagh station, 3 miles.

See also p. 904
Ayr. — District Asylum. — ^Med. Supt.,
G. Douglas McRae, M.D. Access —
Ayr station, 2 miles.

Ballinasloe (Co. Galway). — District
Liinafic Asylum. Res. Med. Supt.,
J. St. L. Kirwan, B.A., M.B. Ac-
cess — Ballinasloe.

Banff. — District Asylum, Ladys-
bridge. Res. Supt., J. Cliisholm.
Vis. Phys., Wm. Fergusson, M.D.
Access — ^Lad^’sbridge station.
Baschurch ( Shropshire) . — B oreatton
Park, 10 miles from Shrewsbury.
Res. Med. Supt., Dr. E. H. O.
Sankey. Access — Baschurch sta-
tion, 2j miles. See also p. 896

MENTAL DISEASES.

I Bath. — Bailhrook House. Res. Med.

I Supt., Norman Lavers, M.D. Ac-
i cess — Bath, 10 minutes’ drive.

Rock Hall House, Combe Down
(for idiot and imbecile children).
Med. Off., D. L. Beath, M.R.C.S.
Clerk, E. N. FuUer, LL.B., 5, Old
King Street, Bath.

Bedford. — Bishopsfone House (for
ladies onty). Prop., Mrs. Peele.
Med. Oft'., Dr. A. Chilimg^vorth.
Access — Bedford.

Sprmgftel'd House Private Asylum,
I hour from London.. Better class
patients only received. Separate
bedrooms. Terms from 3 guineas.
Res. Med. Supt., D. Bower, M.D.
Access — Bedford, i?, miles, M.R.,
and L. & N.W.R. Teleph. No. 17.

See also p. S99
Belfast. — Belfast District Lunatic
Asylum. Res. Med. Supt., Wm.
Graham, M.D. Access — ^Belfast.
Beverley. — Bast Riding of Yorkshire
County Asylum. Res, Med. Supt.,
Dr. M. A. Archdale. Access —
Beverley station, 2 miles.
Birmingham. — Birmi ngham City
Asylum, Rubery Hill, nr. Birming-
ham. Res. Med. Supt., A. C. Suffern,
M.D. Access — Rubery station.

Birtningham City Mental Hospi-
tal, Winson Green. Res. Med.
Supt., Dr. C. B. Roscrow. Access —
Winson Green, |mile; Soho, J mile.
Bodmin. — Cornwall County Asylum.
Res. Med. Supt., Dr. Henry A.
Layton.

Box (Wilts). — Kingsdown House,
5 miles from Bath. Res. Med.
Supt., Dr. H. C. MacBryan. Ac-
cess — ^Box. See also p. 894

Brentwood. — Essex and Colchester
Asylum. Res. Med. Supt., Dr.
John Turner. Access — Brentwood
station, J mile.

MEDICAL ANNUAL

753

MENTAL INSTITUTIONS

Littleton Hall, Brentwood, Essex i
(for ladies). Res. Med. Licensee. |
Dr. H. E. Haynes. Access — i
Brentwood and Shenfield stations,

I'j miles. See also p. 905

Bridgend. — Glamorgan County Asy- '
liiiu. Res. Med. Supt., D. Finlay,
M.D. Access — Bridgend, miles. |

Bristol. — Brislington House. Pro- !
prietress, ^Mrs. Bonville Fox. Res.
Physician, Dr. J. M. Rutherford.
Access — ^Bristol, 3 miles.

City and County Asylum, Fish-
ponds. Res. Med. Supt., J. Vincent
Blachford, M.D. Access — Fish-
ponds station, i mile.

Northwoods House, Winterbourne !
7 miles from Bristol. Res. Med.
Prop,, J. D. Thomas, B.A., M.B.,
B.C. Access — By taxicab from
Bristol, Fishponds, Winterbourne,
or Patch way stations. See p. 901
Stoke Park Colony, Stapleton,
near Bristol (for mentally defective
children). Res. Med. Off., Dr. D.
Fleck. Secretary, National Insti-
tutions for Persons requiring Care
and Control, 14, Ho wick Place,
S.W. Access — Stapleton Road
station, i| miles ; Filton station,

I mile. See also p. go 6

Bromsgrove (Worcs.). — Worcester-
shire Asylum, “ Barnsley Hall.”
Res, Med. Supt., Dr. P. T. Hughes, i
Access — Bromsgrove, M.R., mis. j

Burgess Hill (Sussex). — St. George’s
Retreat. Res. Med. Supt., Dr. F. W.
Apthorp. Access — Burgess Hill '
station. See also p. 906 j

Buxton. — Wye House. Res. Med.

Supt., Graeme Dickson, L.R.C.P.

& S., and Res. Asst. Med, Officers.
Access — Buxton, L. & N.W.R. and
M.R., 10 minutes. See also p, 8co
Caerleon ('Nion.).—Neivpoyt Borough
Asylum. Res. Med. Supt., W. F.
Nelis, M.D. Access — ^Caerleon, h ml.
Cambridge. — County Asylu 7 n. Res.
Med. Supt., Dr. A. D. Thompson.
Access — Cambridge stat., 3^ miles, j
Canterbury. — Stone House, St. Mar-
tin’s, Res. Med. Supt., Dr. E. F.
Sail. Access — Canterbury East.
Cardiff. — Cardiff City Mental Hos-
pital. Res. Med. Supt., E. Goodall,
M.D. Access—Llandaff, T.V.R.,
i mile.

Carlisle. — Cumberland & Westmor-
land Counties Asylum. Res. Med.
Supt., W. F. Farquharson, M.D.
Access — Carlisle, 3 miles.

Carlow. — District A sylwn . Res. Med.
Supt,, Dr. T- A. Greene, Access —
Carlow, ^ mile.

Carmarthen. — ] oint Counties Asylum.
Res. Med. Supt., J. Richards,

F. R.C.S.E. Access — Carmarthen,

2 miles.

■Castlebar (Co. Mayo). — District Asy-
lum. Res. Med. Supt., F. C. Elli-
son, M.D. Access-Castlebar, i mile.
Chartham (near Canterbury). — Ke 72 i
County Asylimt. Res. Med. Supt.,

G. C. Fitzgerald, M.D. Access —
Chartham station, i mile.

Cheadle. — Cheadle Royal Mental
Hospital. Res. Med. Supt., W.
Scowcroft, L.R.C.P., M.R.C.S
Access — Cheadle, 2 miles.

Chester. — Cheshire County Asylum,
Res. Med. Supt., G. Hamilton
Grills, M.D. Station, ij miles.
Chichester. — West Sussex County
Asylum, " GrayVmgwell Hospital.”
Res. Med. Supt., Dr. H. A. Kidd.
Access — Chichester stat., ij miles.
Church Stretton. — Strettoji House.
Shropshire (for gentlemen). Med.
Supt., Dr. A. A. Watson. Res
Med. Off., Dr. J. W. W, Adamson.
Access — Church Stretton station,
i mile. See also p. S94

The Grove House, All Stretton.
Shropshire (for ladies). Res. Prop,
and Med. Supt., Dr. J. McClintock.
Clonmel. — District Asylum. Res.
Med. Supt., Dr. Bagenal C. Harvey,
Access — Clonmel, i mile.
Colchester. — Royal Eastern Counties
Institution for Imbeciles and the
Feeble-minded. Res. Supt. and
Sec., John J. C. Turner. Access —
Colchester.

Cork. — District Asylum. Res. Med.
Supt., Dr. J. J. FitzGerald. Ac-
cess-Cork, 2 miles.

Lindville, Cork. Med. Supt., Dr.
C. A. Osburne.

Cupar (Fifeshire). — Fife and Kmross
District Asylum, Res. Med. Supt.,
A. R. Turnbull, M.B. Access —
Springfield station.

Darlington (Durham), — Dinsdale
Park. Res. Med. Supt., H. W.
Kershaw, M.R.C.S. Access — Dar-
lington, 5 miles ; Dinsdale, i mile.

MENTAL INSTITUTIONS

754

MEDICAL ANNUAL

Middleton Hall, Middleton St. I
George, Co. Durham. Res. Licen.
and Sled. Supt., L. Harris-Liston,
M.D. Access — Dinsdale station,

I mile. See also p. 902

Dartford. — City of London Mental
Hospital, near Dartford. Res.
Med. Supt., Dr. R. H. Steen. Ac-
cess — S.E.R. Dartford, ij miles.

See also p. 892
Denbigh (N. Wales). — North Wales
Counties Asylum. Med. Supt.,
Dr. W* Stanley Hughes. Access — |
Denbigh, i mile. |

Derby. — Borough Asylum, Rowditch.- ;
Res. Med. Supt., Dr. Macphail. ;
Access — G.N.R. station, i mile ; ;
M.R. 2 miles. See also p. 904 '

County Asylum, Mickleover. '
Res. Med. Supt., R. Legge, M.D. ^
Access — Derby, ]\I.R. 5 miles ; ■
Mickleover, G.N.R. , 2 miles. i

Devizes. — County Asylum. ■
Res. Med. Supt., S. J. Cole, M.D., '
Access — Devizes, i mile. i

Dorchester. — The County Asylum, \
“ Herrison.’’ Med. Supt., P. W. 1
Macdonald, M.D. Access — Dor- |
Chester, 3 miles. See also p. 906 |
Downpatrick. — District Asylum. Res.
Med, Supt., M. J. Nolan, L.R.C.P.I.

Sc L.M. Access-Downpatrick, i ml.
Dublin. — Bloomfield, Morehampton
Road. Med, Officer, H. T. Bewley,
M.D. Access — Dublin, i mile.

Elm Lawn, Dundrum, Co. Dublin j
(ladies). Prop., Miss Bernard, j
Vis. Phys., Dr. J. W. Usher. j

Farnham House and Maryville, \
Finglas (for 56 patients, both i
sexes). Res. Med. Supt., H. P.
D’Arcy Benson, M.D., M.R.C.P.,
F.R.C.S. Ed. Access — Cab from
Dublin, 2 miles. Tel. No. 1470
Dublin. See also p. 904

Hartfield House, Drumcondra.
Med. Prop., Dr. F. E. Lynch.
Access — Dublin, 2 miles.

Highfteld (for ladies), Drumcon- |
dra. Hampstead (for gentlemen), '
Glasnevin. Res. Med. Supts., Hy. :
M. Eustace, B.A., M.D., & Wm. N.
Eustace, L.R.C.P.I. & S.I. Access
— ^By rail, Dublin. See also p. 904

Richmond District Asylum, Dub-
lin. Res. Med. Supt., Dr. J.
O’Conor Donelan. Access — Dublin.

St. Patrick's Hospital, James
Street. Res. Med. Supt., Dr. R.
R. Leeper. Branch Asylum at
Lucan.

St. Vincent's Asylum, Fairview,
Dublin. Vis. Med. Supts, John
Murphy, F.RC.P.I. and F. X.
Callaghan, M.D. Apply to the
Superioress,

Stewart Institution, Palmerston,
Chapelizod, Co. Dublin. Res. Med
Supt., F. E. Rainsford, IM.D. Ac-
cess — Kingsbridge station, 2 J- miles.

Verville, Clontarf, near Dublin.
Med. Prop., Dr. F. E. Lynch. Ac
cess — Dublin.

Woodbine Lodge, Rathfarnham,

6 miles (ladies). Prop., Mrs. Bishop.
Med. Supt., Dr. A. Croly. Access —
Rathfarnham tram, 2 miles.

Dudley (Stafford). — Ashwood House,
Kingswinford. Props., Drs. Pea-
cock and Pietersen. Res. Med.
Supt., Dr. Pietersen. Access —
Stourbridge June. 3 J miles, Dudley
station, 4 miles ; Wolverhampton,

7 miles. Tel. : 19 Kingswinford.

See also p. goi
Dumfries. — Crichton Royal Institu^
tion. Res. Med. Supt., Dr. C. C.
Easterbrook. Access — Dumfries,

I mile.

Dundee. — Baldovan Institution (for
the treatment and education of the
feeble-minded). Matron, Miss
Heniy, Med. Supt., D. M. Greig,
F.R.C.S. Access — Dundee, 4 mile.

Royal Asylum and District
Asylum, Westgreen. Res. Med.
Supt., W. Tuach-hlackenzie, M.D.
Access — Dundee, 3 miles ; Lift', 1 1
miles.

Durham. — County Asylum, Winter-
ton. Res. Med. Supt., Dr. H. G.
Cribb. Access — Sedgefield station,
2f miles, by ’bus.

Earlswood. — Training Home for the
Feeble-minded and Imbecile. Sec.,
H. Howard, 14 & 16, Ludgate Hill,
E.C. Res. Med. Supt., Dr. Charles
Caldecott. Access — Earlswood sta-
tion or Red Hill June., i J miles.

House of St. John of God, Still-
organ. Res. Phys., Dr. P. O’Con-
nell. Access — Stillorgan station,
J mile ; Dublin, 5 miles.

I Edinburgh . — Midlothian and Peebles
I District Asylum. Res. Med. Supt.,

I R, B. I\Iitchell, M.D. Access —

Rosslynlee station, i mile.

MEDICAL ANNUAL

755

MENTAL INSTITUTIONS

Hoy at Edinburgh Asylnm, Mom- i
ingside. Res. Phys. Supt., Dr. }
G. M. Robertson. Access — Edin-
burgh, miles.

Xew Saughton Hall, Med.

Supt., J. Batt}’’ Tuke, M.D.,
F.R.C.P. Edin. 'Access — Polton |
station, 5 minutes ; Loanhead, 10 !
minutes’ -walk. See also p. 895 j
Elgin. — District Asylum. Res. Supt., j
Alexander Hendry. Vis. Med. Off., i
Dr. D. G. Campbell. Access —

Elgin, miles.

Ennis. — District Asylum. Res. Med.
Supt., Dr. F. O'Mara. Access —
Ennis station, 2 miles.

Enniscorthy (Co. Wexford). — Dis-
trict Lunatic Asylum. Res. Med.
Supt., Thos. Di-apes, M.B. Ac-
cess — Enniscorthy, i mile.

Epsom (Surrey). — Abele Grove (for
ladies). Prop., Mrs. Atkins. Med.
Supt., E. N. Reichardt, M.D.

The Silver Birches, Church
Street (for ladies). Res. Licensee,
Miss Daniel. Co-Licensee, Dr.
E. C. Daniel. Access — ^L.& S.W.R.
and L.B. & S.C.R., 5 minutes.
Tel. 346 P.O. Epsom. See also p. go6

Exeter. — City Asylum, Heavitree.
Res. Med. Supt., R. L. Rutherford,
IM.D. Access — ^Exeter, 3 miles.

Court Hall, Kenton, near Exeter.
Res. Licensees, Miss Mules, M.D,,
B.S., and Miss A. S. Mules. Ac-
cess — Starcross, i mile.

Devon County Asylum, Exminster,
Res. Med. Supt., Dr. Arthur N.
Davis. Access — Exminster, ij-
miles ; Exeter, 4 miles.

Wonjord House (Hospital for the
Insane). Res, Med. Supt., W. B.
Morton, jM.D. Access — Exeter
station (Queen St.) i J miles ; (St.
David’s) 2 miles.

Fairford ( Gloucestershire). — Fair ford
Retreat. Res. Med. Prop., Dr. A. C.
King-Turner. Access — Fairford.

Glasgow. — District Asylum, Woodi-
lee. Res. Med. Supt., H. Carre,
L.R.C.P.iS: S. Access — ^Lenzie sta-
, tion, I mile ; Glasgow, 8 miles.
Glasgow District Hospital for
Menial Diseases, Gartloch. Res.
Med. Supt., W. A. Parker, M.B.
Access — Garnkirk station, i mile.

Govan District Asylum, Hawk-
head. Res. Med. Supt., Dr. J. H.
!MacDonald. Access — Crookston
station,

Kirklands Asylum, Bothwell.
Res. Med. Supt., James H. Skeen,
M.B. Access — Bothwell & Fallside
stations, A mile ; Glasgow, 9 miles.

Lanark District Asylum, Hart-
wood, Lanarkshire. Med. Supt.,
Dr. N. T. Kerr. Access — Hart-
wood station, \ mile.

Royal Asylum, Gartnavel. Res.
Phys. Supt., Landel R. Oswald, M.B.

Smiihsioji Asylum, Greenock.
Med. Off., Jas. Laurie, M.B. Res.
Med. Off., Dr. Margaret E. Ruther-
furd. Access — Greenock West,
miles.

Gloucester. — Barnwood House. • Res.
Med. Supt., J. G. Soutar, M.B.,
C.M, Access — Gloucester, 2 miles.

See also p. 900
Gloucester County Asylums, Wot-
ton and Barnwood, Gloucester.
Res. Med. Supt., Dr. R. B. Smyth.
Access — Gloucester station, i mile.

Guernsey. — St. Peter Port Asylum.
Med. Off., E. K. Corbin, M.R.C.S.

Haddington, N.B. — District Asylum,
17 miles from Edinburgh. Med,
Supt., H. H. Robarts, M.D.
Access — Haddington station, 10
minutes.

Hatton (near Warwick). — County
Asylum. Res. Med. Supt., A.
Miller, M.B. Access — Hatton
G.W.R. station, 2 miles ; Warwick,
3 miles.

Haywards Heath. — Brighton County
Borough Asylum. Res. Med. Supt.,
C. Planck, M.A., M.R.C.S. Access
— Haywards Heath, ij miles,
Hellingly. — East Sussex County Asy-
lum. Res. Med. Supt., F. R. P.
Taylor, M.D.

Henley-in-Arden (Warwickshire). —
Glendossil and Hurst Houses (for
both sexes). Res. Prop., Dr. S. H.
Agar. Access — Henlev-in-Arden,
G.W.R., J mile.

Hereford. — County and City Asylum,
Res. Med. Supt., C. S. Morrison,
L.R.C.P. Ed. Access-Barrs Court,
G.W., Mid., and L. & N.W.R.
Hereford, 3 miles.

MENTAL INSTITUTIONS

756

MEDICAL ANNUAL

Hitchin (Herts), near. — Three Coun-
ties Asylum. Res. Med. Supt., L. O.
FuUer, M.R.C.S., L.R.C.P. Ac-
cess — ^Three Counties stat., i mile.

Hull. — City Asylum. Res. Med. Supt.,

J. Merson, M.D. Access — ^Willerby
station, i mile. •

Inverness. — District Asylum. Med.

Supt., T. C. Mackenzie, M.D. Ac-
cess — ^Inverness, 2J miles.

Ipswich. — Borough Mental Hospital.
Res. Med. Supt., Dr. E. L, Rowe.
Access — ^Ipswich, 2 miles.

Isle of Man. — Lunatic Asylum, Union
Mills. Res. Med- Supt., W. Richard-
son, M.D. Access — Douglas, 3
miles.

Isle of Wight. — The County Asylum,
Caxisbrooke. Res. Med, Supt.,
Harold Sliaw,M.B. Access — Black-
water, f mile ; Newport, 2J miles.

ADVERTISEMENTS

Medical Defence Union

AND

INDEMNITY INSURANCE

iB2000-ANNUAL COST-7S. 6d.

A special arrangement has been entered into with the Medical
Defence Union whereby the Yorkshire Insurance Company
undertakes to indemnify members of the Union against pecun-
iary loss in costs and damages through adverse verdicts in
actions brought against them, and taken up by the Council,
to the extent of £2000 for a premium of 7/6, or £2500
for a premium of 9/-

Further particulars will be immediately sent on application to any of the
Company's Offices.

Points to he considered by Members of the Medical Defence Union*

(1) Members’ subscriptions not increased, the Indemnity Insurance

being entirely voluntary*

(2) Total annual cost for Subscription and £2000 Indemnity, 17/6, or

{or £2500 Indemnity, 19/-

(3) The indemnity is guaranteed independently of the IMedical Defence

Union by the above old-established Company, possessing
accumulated funds of over three millions sterling.

The . . Established 1824.

YORKSHIRE iNSURANC E COMPANY

Funds Exceed THREE MILLIONS

Chief fSt. Helen’s Square, York.
ofjiccs: iBank Buildings, Princes Street, London, E.C.

The Company transacts the followingr classes of business on
the most favourable terms :

FIRE. LIFE. ANNUITY. GASU/\LTY. TRUSTEE & EXECUTOR.

MOTOR CAR. LOSS OF PROFITS FOLLOWING FIRE.
EMPLOYERS’ LIABILITY BURGLARY.

PERSONAL ACCIDENT. SICKNESS. FIDELITY.

THIRD PAKTY. PLATE GLASS. LIVE STOCK, Etc.

797

INDEX TO LIFE ASSURANCE OFFICES.

A, when Established ; B, C, D, Annual Premiums to Insure £100 on death, with Profits, at the age
0/ 30, 40, and 50; E, Assurance and Annuity Funds, exclusive of Paid-up Capital.
M, Mutual Offices ; p, Proprietary Offices.

Those marked with an asterisk (♦} in the E column have not sent revised figures for 1913.

Title, Etc., of Office.

Abstainers and General Insurance Co., Etd.,
Edmund St., Birmingham. Act. & Sec.,

R. A. Craig A.I.A. . . . . P

Alliance Assurance Co. Etd., Bartholomew

Eane, E.C. Gen. Man., Robert l,ewis P
Atlas Assurance Co. Etd., 92, Cheapside,
E.C. Act., Robert Cross. Gen. Man., Sami.
J. Pipkin .. .. .. P

Australian Mutual Provident Society,
lyife, Endowments and Annuities, 37,
Threadneedle Street, E.C. ,Res. Sec., A. C.
Hollingworth. Further particulars see
page 803 . . . . . . , WI

Britannic Assurance Co. Ltd., Eife, En-
dowment Assurances, House Purchase,
Broad Street Comer, Birmingham. Chairs
man, F. T. Jefferson, J.P. Secretary, J. A.
Jefferson, F.I.A. Further particulars
see page 802 .. .. P.

British Equitable Assurance Co. Ltd., r, 2, 3,
Queen Street Place, E.C. Manager, Basil
May, F.I.A. . . . . . . P

Caledonian Insurance Co., 19, George Street,
Edinburgh. Gen. Man., Robert Cliapman.
London Offices, 82, King William Street,
E.C., and 14, Waterloo Place. S.W. P
Canada Life Assurance Co., 15, King Street,
Cheapside, E.C. Man., A. D. Cheyne p
City of Glasgow Life Assurance Co., 30, Ren-
tield Street, Glasgow. Gen. Man., William

S. Nicol. I,ondon Office, 12, King William
St., E.C. London Man., L. Campbell p

City Life Assurance Co. Ltd., 6, Paul Street,
Finsbury, E-C. Ma?i. Director, M. Gregory
Clergfy Mutual Assurance Society, Life,
2 & 3, Sanctuary, Westminster. Act. and
Man., F. B. Wyatt. Sec., W. N. Neale.
Further particulars see page 801 M
Clerical, Medical, and General Life Assurance
Society, 15, St. James’s Square, and i,King
William Street, E.C. Act. & Sec., A. B.
Besant , . . . . . P

Colonial Mutual Life Assurance Society Ltd.,
33, Poultry, E.C. Man., Arthur E. Gibbs.
Sec., W. N. Dewar . . . . M

Commercial Union Assurance Co. Ltd., 24, 25,
and 26, Cornhill, E.C. Ac/., A. G. Allen p
Co-operative Insurance Society Ltd.,
109, Corporation Street, IVIandiester. Sec.,
James Odgers. Further particulars see
page 804 • • . . . . P

Eagle Insurance Co., 79, Pall Mall, S.W. Man.
& Act., F. B. Galer, B.A., F.I.A. Sec.,
J. F. E. Hall . . . , P

Edinburgh Life Assurance Co., 26, George
Street, Edinburgh. Man., T. M. Gardiner.
Sec. & Act., A. E. Sprague, D.Sc., F.F.A.,

• F.I.A. London, 3, Birchin I^ne,E.C. Sec.,
J. J. Bisgood . . . . . , P

English and Scottish I.aw Life Assurance
Association, 33, St. James’s Square, S.W^
Gen. Man., Albert G. Scott. Act. & Sec.,
J ohn Spencer, F.I.A. . . . . P

1SS3

40/11

55/10

S2/3

699,695

1S24

4 S/9

64/5

90/9

7,343.4/7

1S08

49/3

63/7

ss/s

2,202,329

1849

4S/3

64/5

89/10

30,007,658

1866

48/6

65/2

94/-

3,300,000

1854

4S/8

64/11

91/9

1,663,364

iSo5«

48/9

64/6

88/6

3,147,665

1847

48/9

65/10

96/8

9,608,711

1838

48/9

64/6

89/6

3,174,803

1897

44/1

60/11

S9/7

*463,385

1829

46/4

62/2

S7/4

4,676,274

1S24

48/7

66/9

96/3

'’5,468,071

1S73

47/4

63/2

S9/9

3,500,000

1861

47/10

65/2

92/4

5,181,487

1867

47/4

63/1

90/1

*203,696

1807

48/7

64/5

89/10

2,066,220

1823

47/1 r

64/2

90/2

4,334,221

1839

! 47/1

62/8 1

87/9

3,030,678

79 S life assurance

A, •when Estahlkhed ; B, C, D, Annual Premiums to Insure £100 on death, with Profits, at the age
of 30, 40, and 50; K, Assurance and Annuity Funds, exclusive of Paid-up Capital,
M, Mtitual Offices : P, Proprietary Offices.

Those marked with an asterisk in the E column have not sent revised figures for 1913.

Title, Etc., of office.

E(jnitable Life Assurance Society, l^fansion
House Street, E.C. Act. & Man., W. P.
Elderton. . , . . . . M

Equity and Law I.ife Assurance Society, 18,
Lincoln’s Inn Fields, W.C, Act. & Sec.,
W. P. Phelps, M.A., F.I.A. .. P

Friends' Provident Institution, Bradford,
Yorkshire. S^c., William H. Gregory. Act.,
Alfd. Moorhouse, F.I.A. .. M

General Accident Fire and Life Assurance
Corporation Ltd., Perth, Scotland. Gen.
Man., F. Norie-Miller, J.P. . . P

General Life Assurance Co., 103, Cannon
Street, E.C. Man. <& Sec., John Robert
Frecinau. Further particulars see page
802 . . . . . . . . P

Greshrim Life Assurance Society Ltd., St.
Mildred’s House, E.C. Man. & Sec.,
Alexander Law’son. , . . , P

Guardian. Assurance Co. Ltd., ii, Lombard
Street. E.C., and 21, Fleet Street. Sec.,
T. G. C. Browne. Act., Ernest Woods P
I, aw Union and Rock Insurance Co. Ltd.,
Old Serjeants Inn, Chancery I.ane. Gen. !
A/a«., R. Stirling. . . . . P

Legal & General Life Assurance Society, 10,
Fleet St., E.C. A ct. & Man., E. Colquhoun p
Life Association of Scotland, 82, Princes St.,
Edinburgh. Man., Gordon Douglas. Sec.
R. jM. M. Roddick. London Office, 28,
Bishopsgate, E.C. Sec., J. C. Wardrop P
Liverpool and London and Globe Insurance
Co. Ltd., T, Dale Street, Liverpool. Gen.
Man. & Sec., A. G. Dent. I.oudon Office,
r, CornhiU, E.C. . . . . P

London and Lancashire Life and General
Assurance Association Ltd., 66, 67, Conihill,
E.C. M«h., W. -Eneas Mackay. Sec.,

I,ouis I. Jarvis. Jnt. .Asst. Secs., E. E. Dent
and L. C. Kestin. Harold Dougharty,

A.I.-A., .F.C.I.S. . . . . P

London Assurance Corporation, 7 » Royal
Exchange, E.C. Man. oi Life Dept., James
Climes. AlcL, A. G. Hemming .. P

London Life -Association, Ltd., 8r, King
WilUam Street, E.C. Act. & Man.,
H. M. Trouncer, M.-A , F.T.-A, . . IVI

Marine and General "Mutual Life Assurance
Society, 14, J.eadenhall Street, E.C. Act.

& Sec., &. Day, F.I.-A. . . IVI

Metropolitan Life Assurance Society, 13, Moor-
gate Street, E.C. Sec., Bernard Woods.
Act., H. J. Baker, F.I.A. . . IVI

Mutual Life and Citizens’ Assurance Co. Ltd.
(of Australia), Effingham Ho., i, Arundel St.
W.C. S^’c.,-Ale-x.S.Sellar,M.A.,F.F.A. p
Mutual Life Insurance Co. of New York, r6,

17 and x8, Cornhill. E.C. Gen. Man., J. H.
Harrison Hogge. Sec., T. Crawford M
National Mutual Life -Assurance Society, 39,
King Street, Cheapside, E- C. A ct. & Man. ,
Geoffrey Marks, F.I.A. Sec., H. J. Lock-
wood. . 4 ssi. Act.,C. R. V. Coutts, F,I.-A. IVI
National Mutual Life Association of
Australasia, Ltd,, 5 i Cheapside, E.C.
Man., H. W. Meyers, further par-
ticulars see page 804 .. M

National Provident Institution, 48, Grace-
church Street, E.C. Act. & Sec., L. F.
Hovil . . . . . . M

1762

53/5

67/11

90/7

5,400,103

1844

48/10

64/6

90/9

*4,751,328

1832

48/-

64/-

89/7

3,380,305

I8S5

49/2

64/11

91/3

109,073

1837

49/10

65/4

92/S

2,013,299

I84S

48/2

64/1

91/5

10,282,617

1821

48/10

64/6

89/3

4,387,523

1806

48/4

64/-

89/10

*7,818,008

1836

50/9

65/11

90/9

*8,062,541

I83S

48/11

64/10

91/1

5,975,131

1836

49/10

65/9

91/3

5,073,974

1862

i 4S/9

' 84/9

91/2

1 3,669,525

1720

' 49/-

64/8

90/a

2,580,124

zSo6

60/-

79/- !

! io8/-

5,328,395

1852

48/10

65/-

91/6

1,978,497

1835

49/9

66/4

92/-

2,331,189

18S6

48/9 i

65/3

89/9

S.209,353

1843

48/9

66 /-

97 /“

121,417,540

1830

4S/4

63/7

89/6

3,040,849

1869

46/8

61/6

87/2

*7,000,000

X835

50/a

66/3

91/1

7,172,893

LIFE ASSURANCE

799

hen Established ; B, C, D, Annual Premiums to Insure £100 on dealli^ •with Profits^ at the age
of 30, 40, and 50; E, Assurance and Annuity Funds, exclusive of Paid-up Capital,
M, M^ltual Offices ; p. Proprietary Offices.

Those marked with an asterisk (*) in the E column have not sent revised figures for 1913.

Title, Etc., of Office.

York I.ife Insurance Co., Trafalgar
hidings, Trafalgar Square, London, W.C.
c.,\Vra.R.Collin 3 on.F.C.I.S. .. M

1S45

4S/9

66/-

96/11

147,879,800

th British and Mercantile Insurance
Fire, Life, Annuities, 61, Threadneedle
E.C„ and 64, Princes St., Edinburgh.
fe Man. & Act., London, H. Cockburn.
•>me Fire & Jt. Life Man., D. C. Halde-
in. Sec., R. Carmichael. West End
6ce, 7, Waterloo Place, S.W. Man.,
C. Haworth-Booth. Further par-

3ulars see page cxxii . P

1S09

49/10

66/ 1

qr/ii

15,645,125

hern Assurance Co. Ltd., i, Moorgate
reet, E.C. Gen. Man., H. E. Wilson P

1836

49/-

64/ S

90/10

5,259,609

vich Union I.ife Insurance Society*,
jrwich. Gen. Man. & Act,, Davidson
alker. London Office, 49, Fleet St., E.C.

1808

45/8

59/6

85/3

11,600,17s

1 Life Assurance Co. Ltd., High Holboni,
.C. Jilt. Man'g Directors, F. D. Bowles,
iq., J.P., C.C., and G. ShrubsaU, J.P. P

1864

49/-

65/-

92/-

7,845.442

nix Assurance Co. Ltd., 19 &70, Lombard
reet, 57, Charing Cross, and 187, Fleet
reet, E.C. Gen. Man., Sir Gerald H.
ran, F.I.A. .. .. p

1782

48/11

64/7

90/8

*10,360.677

ident Clerks & General Mutual Life
isurance Association, 27 & 29, Moorgnte
E.C. Sec., John E. Gwyer M

1S40

46/4

62/8

92/2

2,890,726

dential Assurance Co. Ltd., Holboni
irs.' Jni. Secs., D. W. Stable and J. Smart
irther particulars see page 803 P

1848

49/6

65/11

91/11

44,504,184

ge Assurance Co. Ltd., Oxford Street,
inchester. Joint Mans., Philip Smith and
,mes S. Proctor. I.ondon Office, 133,
rand, W.C. . . . . . . p

1864

49/3

65/9

91/9

8,883,505

il Exchange Assurance Corporaticn,
Dyal Exchange. E.C., and 44, Pall Mall,
W. Act., H. E. Nightingale, F.I.A. P

1720

49/-

64/9

90/2

4,433,240

il Insurance Co. Ltd., i, North John St.,
verpool. Man., G. Chappell. London
Sees, 24-28, Lombard Street. Sec., R.
'Connell . . . . . , P

1845

48/8

64/4

90/4

10,950,488

tre I,ife Association Ltd., 40, Finsburv
ivemeut, E.C. Sec., W. E. Wright P

1864

i 48/8 '

64/S

90/6

1,241,202

tish Amicable Life Assurance Society,

. Vincent Place, Glasgow. Man., W.
utton. Sec., C, Guthrie , . M

1826

51/9

66/3

go/ 1

5,941,315

ti.sh Equitable Life Assurance Society, 28, 1
. Andrew Square, Edinburgh. Man. &
:t., G. M. Low. Sec., J. J. McLauchlan.
)iidou Office, 13, Comhill, E.C. Sec.,
W. Purves. . . . . M

1831

50/-

65/5

90/6

6,110,323

tish Life Assurance Co. Ltd., 19, St.
idrew Square, Edinburgh. Man., Sir
ivid Paulin, F.R.S.E. London Oftice, 13,
eraents Lane, E.C. Sec., Geo. Struthers p
tish Metropolitan Life Assurance Co.
d., 25, St. Andrew Square, Edinburgh,
mdon Office, 66, 67, Comhill, E.C. Sec.,
S. Goggs . . . . . . P

i88i

! 49/5

64/6

90/5

1,875,497

1876

40/8

54/7

79/7

*844,584

tish Provident Institution, 6, St. Andrew
[uare, Edinburgh. Man., J. G. Watson.
'C.,R. T. Boothby. Joint Asst. Secs,, C. W.
lomson & Jas. C. Lindsay. Act., W. G.
alton. London Offices, 3, Lombard St.,
C., and 17, Pall Mall, S.W. . . M

1837

42/4 i

i 56/6

83/2

15,386,007

tish Temperance I.ife & Accident Insur-
LCeCo.,Ltd., 109, St. Vincent Street, Glas-
w. M anager, Adam K. Rodger. London,

3 & 4, Cheapside. Man., W. A. Bowie,
rss 10 per cent to Whole Life Abstainers p ;

1883

48/6

63/9

89/10 ,

1.946,441

LIFE ASSURANCE

800

A, When Established ; B, C, D, Annual Premiums to Insure £100 on death, with Profits, at the age
of 30, 40, and 50 ; E, Assurance and Annuity Funds, exclusive of Paid-up Capital.
M, Mutual Ofices ; p. Proprietary Offices.

Those marked with an asterisk in the E column have not sent revised figures for 1913.

Title, Etc., of Office.

Scottish Union & National Insurance Co., 35,
St. Andrew Square, Edinburgh. Ge 7 i. Man.,
J. A. Cook. London Office, 5, Walbrook,
E.C. Sec., James G. Nicoll . . P

1824

48/9

64/6

89/6

5,126 704

Scottish Widows' Fund Life Assurance
Society, 9, St. Andrew Square, Edinburgh.
Ma 7 i. & Act., G. J. Lidstone. Sec., J. G. C.
Cheyne, London Offices, 28, Cornhin, E.C.,
and 5, Waterloo Place, S.W. Sec., R.
Maclure. . . . . . . M

1815

51/9

66/3

90/7

‘‘'21,500,000

Standard Life Assurance Co., 3, George Street,
Edinburgh. Leonard W. Dickson.

l,ondon Offices, 83, King William St., and
3, Pall Mall East. Sec., C. E. Fox p

1825

48/11

64/3

89/-

13,190,851

Star Assurance Society, 3a, IMoorgate Street,
E*C. Gen. Man., J. Douglas Watson. p

1S43

49/9

66/3

93/8

7,022,258

Sun Life Assurance Society, 63, Thread-
needle Street, E.C. Act., R. G. Salmon,
F.I.A. Sec. & Geti. Man., E. Linnell P

1810

49/2

66/6

94/2

9,661,999

Sun Life Assurance Co. of Canada, Canada
House, 4 & 5, Norfolk Street, W.C. Man.,
J. F. Junkin,. .. .. p

1865

48/6

65/4

94/1

9,865,739

United Kingdom Provident Institution, 196,
Strand, W.C. Sec., H. W. Hasler M

1840

49/6

65/-

91/ro

9,576,308

University Life Assurance Society, 25, Pall
aiall, S.W. Act. & Sec., R. Todhunter,
M.A. .. .. P

1823

49/ i I

6.'5/4

91/5

954,850

Wesleyan 6c General Assurance Society,
I.ife, Annuities, Sickness, Assurance Build-
ings, Steelhouse Lane, Birmingham. Gen.
Man. A. L. Hunt. London Office, loi,
Finsbury Pavement, E.C. Further par-
ticulars see page 802 .. IVI

1841

48/1

65/S

93/10

2,000,000

Yorkshire Insurance Co. Ltd., Chief
Offices; St, Helen’s Square, York. Bank
Buildings, Princes Street. IS.C. London
Branches, 55, Eall Mall, S.W.; 49, Sloane
Square, S.W,; 222-225, Strand, W.C.; 133,
Newington Crescent, S.E., 43, Broadway,
Stratford, S.E. Further particulars see
page 796 .. .. .. P

1824

49/x

64/9

1 91/7

3,272,397

Medical Sickness and Accident Society, 33, Chancery Lune, W.C., Sec., Bertram. Sutton.
Mutual. Established 1884. Assurance and Annuity Funds £260,000,

ADVERTISEMENTS

8oi

r iergy Mutual

Assurance Society.

The ONLY LIFE ASSURANCE SOCIETY
specially for

THE CLERGY & THEIR RELATIVES

which spends nothing either in Dividends to Share-
holders or in Commissions to Agents.

ALL THE PROFITS ARE DIVIDED
AMONGST THE POLICY HOLDERS.

After 84 YEARS of steady growth the Society’s Funds
are £4,6769274, The BONUS distribution in 1911
amounted to £55399959 ^delding Bonuses at the same
exceptionally high rates as in 1906.

While Bonuses are EXCEPTIONALLY HIGH, pre-
miums are LOW. Interim Bonus is paid on policies
which mature between two Bonus periods. B'ullest
value is given for policies surrendered. Policies are
incapable of forfeiture so long as their Nett Surrender
value exceeds the arrears of premium.

The Society grants

Whole Life Assurances

Endowment Assurances

Guaranteed Income Assurances

Deferred Assurances on children’s lives

Educational Annuities

Immediate Life Annuities

Pension policies

Policies of Assurance to meet DEATH DUTIES and DILAPIDATIONS
are granted by the Society at low rates. For information as to these or
other forms of Life Assurance, apply to the Secretary, W. N. Neale, Hsq.,
2 & 3, The Sanctuary, Westminster, S.W.

Patrons; THE ARCHBISHOP OF CANTERBURY; THE ARCHBISHOP OF YORK.
President; THE BISHOP OF LONDON. Vice-President; THE LORD HARRIS.
Chairman; SIR PAGET BOWMAN, Bart.

Deputy Chairman ; THE REV. PREBENDARY HARVEY.

Actuary and Manager; FRANK B. WYATT, Esq., F.I.A.

CLERGY MUTUAL Assurance Society.

ADVERTISEMENTS

General Life Assurance Go.

ESTABLISHED 1837.

FUNDS BXCEED - - - £2,000,000

BOARD OF DIRECTORS:

ALFRED JAMES SHEPHEARD, Esq.

Defiuiy Chairuictn — Right Hon. Viscount VALENTIA, C.P».. M.V.O., M.P.

H. T. P>RACB:Y, Esq. I Sir JOHN JARDINE, K.C.I.E., M.P.

H. E. DUKE, Ksq., K.C. M.P. C. K. VERNON RUTTER, Esq.

Hon. R. C. GROSVENOR | ROBT. HENRY SCOTT, Esq., F.R.S., D..Sc.

MEDICAL OFFICERS:

FREDERICK TAYLOR, Esq., M.D., 20, Wimpole Street, W.

HERBERT FRENCH, Esq., M.D. 62, Wimpole Street, W.

Advances made on Reversions, Life Interests, and on Personal Security in connection with a Life
Policy. Si.v per cent permanent reduction to Medical Men upon With Profit tables.

^ ^^London?*E^c.*^*' JOHN ROBERT FREEMAN, Manager S Secretary,

Wesleyan & General

EMPOWERED BY
SPECIAL ACT OF
P.\RLIAMENT,

Assurance Society

ESTABLISHED 1841.

Cbief ©fKccs:

ASSURANCE BUILDINGS, STEELHOUSE LANE, BIRMINGHAM.

Branch in all London Br.vnch OFFICE .. loi, Finsburv Pavement

and Asides ” 9 & lo, C.-arence Chmbr^, P.CMD.LLY

,krousUo«t H,c Ki.Ida..,. ,, ^34. Sr.^'.^CE^T &

Accumulated Funds exceed £2,000,000. Claims Paid exceed £6,800,000.
ANNUAL VALUATIONS & DISTRIBUTION OP PROFITS.

Cej'ics o/ the Annual and Vnlnaiion Records, Pros^ecitiscs with reznsed rates of Premhitns.
may be had on application,

A. L. HUNT, General Manager.

Britannic Assurance Go. Ld.

ESTABLISHED 1866.

INDUSTRIAL & ORDINARY BRANCHES.
LIFE. E NDOWMENTS. HOUSE PURCHASE.

Allied with

NATIONAL AMALGAMATED APPROVED SOCIETY for
NATIONAL HEALTH INSURANCE.

TOTAL FUNDS BXGEBD - - £3,450,000
CLAIMS PAID „ - - £9,350,000

J. A. JEFFERSON, F.I.A., Secretary,

Chief Offices :-BK0 AD STREET CORNER, BIRMINGHAM.

ADVERTISEMENTS

S03

Supremacy of the

(Australian Mutual Provident Society.)

S There are more than 80 Offices dolns: Life Assurance business in the
United Kins:dum. The Benefits granted by such Offices vary to an
enormous extent.

Taking examples from Stone & Cox’s Bonus Table (1913 issue), we find that for each ^10 of Annual
Premium paid by a man effecting an ordinary Whole Life Policy, the BEST RESULTS
shown are as follows :

THE BK5T RESULTS are those of the

AUSTRALIAN MUTUAL PROVIDENT SOCIETY (The A.M.P.)

Arising under a system of Annual Distribution of Bonus and a Scale
of Premiums unchanged since the foundation of the Society in iS^g.

“A stronger Life Office does not exist, and the bonus record of the Society is truly remark-
able .” — Saturday Review^

“The conditions it now presents make the maintenance or improvement of its returns to
policy-holders practically certain .” — The Insurance Spectator,

AUSTRALIAN MUTUAL PROVIDENT

SOOIETY,

37, THREADNEEDLE STREET, LONDON, E.O.

Funds (1912), S.30.000,000 Annual Income, £3,750,000

PRUDENTIAL

ASSURANCE COMPANY, LTD.

HOLBORN BARS, LONDON.

Directors :

THOMAS CHARLES DEWEY, Esq., Chainiiaii,

Sir WILLIAM LANCASTER. Deputy ^Chairman.

JOHN IRVINE BOSWELL, M.D. Sir JOHN HENRY LUSCOMBE
Surg. Lieut.-Col, H. R. ODO CROSS WILLIAM THOMAS PUGH, Esq.
Sir PHILIP GREGORY FREDERICK SCHOOLING, Esq.

WILLIAM EDGAR HORNE. Esq., M.P. THOMAS WHARRIE, Esq.

Joint Secretaries : D. W. Stable, Esq., J. Smart, Esq.

Assistant Secretary : G. E. May, Esq. Actuary : J. Burn, Esq.

Assistant Managers :

F. Haycraft, Esq., H. Blennerhassett, Esq., W. E. Martin, Esq.
(ieneral Manager: A. C. Thompson, Esq.

Every description of Life /^ssurance and Annuity Busir\ess Trat^sacted.

INVESTED FUNDS EXCEED - £88,000,000

CLAIMS PAID - . - - £110,000,000

The Last Annual and Valuation Reports can be had on application.

ADVERTISEMENTS

S04

The National Mutual

LIFE ASSOCIATION

OF AUSTRALASIA. Ltd.

Funds over jSSfOOOiOOO Annual Income over ^1.350.000
New Business over £3)500}000 per annum^

NO SHAREHOLDERS. PURELY MUTUAL.

PREMIUM RATES—

10 per cent below average of English and Foreign Offices.

OHIUDREIM’S ENDOWMENTS—

A specially attractive popular scheme — "A Child's Birthright”'
— premiums ceasing on death of parent.

ANNUITIES—

The Association is THE BEST OFFICE FOR ANNUITIES.
Return generally J per cent better than most Offices — in some
cases the difference is as much as 2 per cent per annum.

LARGE BONUSES LIBERAL CONDITIONS

Chief Office for Great Britain and Ireland: 6 CHEAPSIDE, LONDON, E.C.

Jlfana^er: H. W. MEYERS.

GO OPERATIVE INSURANCE SOCIETY^

The joint INSURANCE DEPARTMENT or the C.W.S. and the S.C.W.S.

109, CORPORATION STREET, MANCHESTER,

for

LIFE, WORKMEN'S COMPENSATION, “ THIRD-PARTY ACCIDENT,
PLATE GLASS, FIDELITY, BURGLARY, and FIRE INSURANCE.

Third £^ditwn Reprint, Coloured Frontispiece, 41- net„

MEDICAL EXAMINATION tor LIFE ASSURANCE: with Remarks

on the Selection of an Office, and a Coloured Frontispiece showing the Special Rating Areas.
By F. de H.wlland Hall, M.D., F.R.C.P, [Bristol: John Wkight & Sons Ltd.

Telephones: Hammersmith 109 & 1128. Telegrams*. Bondonner, London*''

Funeral Director

I W. S« BOND. Chief Offices: 21 8t 22 Shepherd’s Bush Green,

■ [ 2 Church Rd., Acton; 42 High St.. Ealing; 127 High Rd., Chiswick ;

® - *2 Devonshire Rd., Chiswick ; 36 Fulham Palace Rd., Hammer-

smith ; 366 Uxbridge Rd., Shepherd's Bush; 28 Norland Rd.,
Netting Hill ; 4 Railway Approach, Northfield Av., West Ealing.

Prompt Attention.

Branches

Experienced Staff of Assistants.

ADVERTISEMENTS

Swains

Blocks.

dOHN

SWMN

&SON.

uMirmo

^PLE MEDICAL CARO INDEX SYSTEM & YEAR BOOK.

School Dental Clinic Card Index System.

Saves Tine knd Worry, increases Returns, call be commenced at any time.

Prospectus and Specimen Cards FREE.

All Work is executed on the Premises, under our Personal Supervision.

Ianatomical diagramsI

For LECTURES
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'• and STUDENTS thereat.

Clinical Figures & Charts

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Speciality : Tuberculosis and Hygienic Models and
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MIDDLESEX HOSPITAL

MEDICAL SCHOOL

(University of London,)

T he Hospital and Medical School are fully equipped for teaching the
entire medical curriculum, including instruction in Maternity Wards.-

HOSPITAL APPOINTMENTS,

The following appointments, besides the usual Clerkships and Dresserships,
are open to all General Students without extra fee: —

Special I ^ appointments annually for 6 months.

House Ph 3 ^sicians 6 ,,

House Surgeons 8 ,, n »»

Obstetric House Surgeons ... 2 ,, ,, »,

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vacancies arise (salary £40 a year each).

The Medical and Surgical Casualty Officers are appointed in the same
manner (salary S.50 a year each, with board and residence).

SCHOLARSHIPS AND PRIZES.

Three Entrance Scholarships, of the value of £100, £50, and £25
respectively, and a University Scholarship in Anatomy and Physiology,
value of £50, open to Students of Oxford and Cambridge Universities who
have already passed or completed the curriculum for the professional examina^-
tions in Anatomy and Physiology, are offered for competition at . the com-
mencement of the Winter Session,

Two Broderip Scholarships, of the value of £60 and £40 respec-
tively, are awarded every year for proficiency in Clinical Knowledge; :

The Murray Gold Medal and Scholarship (£25), founded in
connection with the University of Aberdeen, is awarded every third year to a
Student of the Middlesex Hospital.

The following are awarded annually : —

The Hetley Prize, value £35 (Clinical Medicine, Surgery and Obstetrics).

The Lyell Medal and Scholarship, value £55 (Surgical Anatomy and Practical Surgery).

The Leopold Hudson Prize, value 11 guineas (Surgical- Pathology and Bacteriology).

The Freeman Scholarship, value £30 (Obstetric Medicine and Gynaecology).

Second Year’s Hlxhibition, value £10 lOg. (Anatomy and Physiology).

“Emden” Cancer Research Scholarship, £100.

“Richard Hollins” Research Scholarship, £106.

Salters’ Company Cancer Research Scholarship, £100.

Cancer Research Scholarship, £60.

New Zealand Students’ Scholarship, the Clinical advantages of the Hospital for 1 year Free,

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Examinations, without extra fee ; thus the necessity of obtaining private
instruction is obviated^

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Fiill particulars may be obtained on application to —

H. CAMPBELL THOMSON, M.D., F.R.C.P., Dean ol the Medical School,

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843

St.lV|ARY’S HOSPITAL IV|EDIGAL SCHOOL

{.university of LONDON.)

SESSIONS 1914 .

Students may conveniently commence work on any of the following dates

Tues. JAN. 6th, 1914 ; Tues, 21st, 1914; Thuis. GOT. 1st, 1914.

THE MEDICAL SCHOOL is situated in the Paddington District of the
West End of London, and being in close proximity to five Railway Stations, is
easy of access from all parts of the hletropolis and Suburbs. An official register
of Students’ rooms in the neighbourhood, and of private families who receive
students as boarders, is kept in the office of the Medical School. The Athletic
Clubs’ Ground at Park Royal, Acton, is easily accessible from the Medical
School.

Five Entrance Scholarships in Natural Science, value from £ioo to
£26 5s. are awarded annually by Examination in September.

COURSES OF STUDY.

Instruction is provided in all subjects of the curriculum, under Recognised
Teachers of the University of London, as follows : —

(a) Preliminary Scientific. — Complete Courses in Chemistry, Physics,
and Biology. Students can join in January, April, or October.

(b) Intermediate. — Systematic Courses of Anatomy, Physiology, and
Pharmacology, with Special Tutorial Classes for the 2nd M.B. London and
Primary F.R.C.S.

(c) Final. — Systematic Lectures, Clinical Instruction, and Tutorial Classes
in Medicine, Surgery, Obstetrics, and the various Special Departments. Full
Laboratory Courses in General and Special Pathology ; also in Bacteriology
and Chemical Pathology, with especial reference to their clinical application.

CLINICAL PATHOLOGY AND OPSONIN DEPARTMENT.

Advanced Courses of Clinical Pathology and Bacteriology, under the
direction of Sir Almroth Wright, F.R.S., are” held throughout the year, an’d
practical experience in Opsonic Investigation may be obtained in the Depart-
ment of Therapeutic Inoculation,

RESIDENT MEDICAL OFFICERS.

Twenty are appointed Annually by Competitive Examination.

HOSPITAL STAFF.

Consulting Physician — ^Dr. lyEES.

Consulting Surgeons— -'Mr. EDMUND OWEN, Mr. H. W. PAGE, Mr. A. J. PEPPER ; (Ophthal-
mic) Sir G, A. CRITCHETT, Mr. H. E. JUUER ; (Skin) Sir MAI.C01,M MORRIS ; (Dental)
Mr. MORTON SMAEE ; (Throat) Dr. SCANES-SPICER ; (Obstetric) Dr. M. HAND-
FIEED-JONES ; Consulting Aniesthetist • Mr. HENRY DAVIS.

Physicians— D t. S. PHTUhIPS, Dr. WILFRED HARRIS, Sir TOHN BROADBENT, (Out-
patients) Dr. W, H. WIEECOX, Dr. R. H. MIEEER, Dr. F. S. EANGIMEAD.

Surgeons— Ur. J. E. EANE ; Mr. V. \V. EOW ; Mr. W. K. CEAYTON-GREENE ; (Out-patients)
Mr. MAYNARD SMITH, Mr. FITZWIEEIAMS, Mr. V. Z. COPE.

Obstetric Surgeons— -Dx. W. J. GOW. (Out-patients) Dr. T. G. STEVENS.

Ophthalmic Surgeon — ^IMr. EESETE PATON. Assistant Ophthahnic Surgeon — ^3Mr. G. COATS.

Surgeons to Ear, Nose and Throat Department — Dr. HIEE, Mr. C. I. GRAHAM.

Physician to Skin Department — ^Dr, GRAHAAI EITTEE.

Physician to Department for Mental Diseases — ^Dr. R. H. COEE.

Dental Surgeon — ^Mr. W. H. DOEAMORE.

X-Ray Medical Oficer—Dr, HARRISON ORTON.

Directors of Inoculation Department — ^Sir AI^MROTH WRIGHT, F.R.S., Capt. S. R. DOXTGEAS,
I.M.S. (Assistant).

LECTURERS.

Clinical Medicine — ^Dr. PHIEEIPS
Clinical Surga^y — ^Mr. EANE
Medicine— Dx, HARRIS, Sir JOHN BROAD-
BENT, Dr. WIEECOX
Surgery— MX, EOW, Mr. CEAYTON-GREENE
Practical Surgery— Mx. MAYNARD SMITH,
Mr. FITZWIEEIAMS
Pathology— Six AEMROTH WRIGHT, F.R.S.

Dr. SPIESBURY, Dr. KETTEE (Asst.Eect.)
Bacteriology — Capt. DOUGEAS, I.^I.S.

Pathological Chemistry— Dt, W. H. WIEECOX

Midwifery — Dr. GOW

Pharmacology — Dr. R. H. MIEEER

Forensic Medicine — Dr. WIEECOX

Hygiene — ^Dr. WIEECOX

Mental Diseases — ^Dr. COEE

Neurology — ^Dr, HARRIS

Anatomy — ^Mr. J. ERNEST FRAZER

Physiology and Histology — Dr. H. E. ROAF

Biology— Dx, RIDEWOOD

Chemistry— Dv, G. SENTER

Physics — ^Mr. W. H. WHITE

For Calendar of the Medical School, giving full information as to Courses of Study, Fees,
etc., apply to the Dean, Sir JOHM BROADBBNT, or to Mr, B. E. MATTHEWS, School Sec.

$44

ADVERTISEMENTS

UNIVERSITY of BRISTOL.

FACULTY OF MEDICINE.

The University affords complete courses of instruction for its own exam-
inations, those of the University of London, and those of the Conjoint Board,
etc., for Medical Degrees or Diplomas. The Dental and Public Health
Departments afford the necessary instruction for the Degrees and Diplomas
of the University and of other examining bodies in those subjects.

The University confers the following Degrees and Diplomas : —

Bachelor of Medicine and Bachelor of Surgery M.B., Ch.B.
Doctor of Medicine . . . . . . . . . . M.D.

Master of Surgery . . . . . . ; . . . Ch.M.

Bachelor of Dental Surgery . . . . . . B.D.S.

Master of Dental Surgery . . . . . . M.D.S.

Licentiateship of Dental Surgery . . . . L.D.S.

Diploma in Public Health . . . . . . . . D.P.H.

The early part of the curriculum so interlocks with the curriculum for the
B.Sc. that the Medical student may without much loss of time take also the
degree of B.Sc. Moreover, the Dental student may in seven years take both
Dental and Medical degrees. Magnificent Ph^’siological and Chemical depart-
ments have recently been opened, and new laboratories have been provided
for Mechanical Dentistry and Dental Metallurgy. The whole of the Dental
Mechanical work for the Bristol Royal Infirmax*y and the Bristol General
Hospital is done in the University laboratory by the students, instructed by
a skilled mechanic.

CLINICAL WORK is done at the Bristol Royal Infirmary, and the
Bristol General Hospital, which together contain over 400 beds. The Bristol
Royal Hospital for Sick Children and Women, the Bristol Eye Hospital, the
Bristol City and County Asylum, and the Bristol City Fever Hospital are also
open for the clinical instruction of students.

SCHOLARSHIPS. — There is no entrance scholarship, but students from
the City of Bristol may, on their merits, receive financial aid from the City
Scholarship Fund on application to the City Scholarship Committee.

Several Scholarships and Prizes are open to students during their Hospital
career.

HOSPITAL APPOINTMENTS open to students after qualification.

At the Bristol Royal Infirmary. — ^Two House Surgeons, two
House Physicians (of these one is chosen as Senior Resident Officer) ,
one Resident Obstetric Officer, one Throat, Nose and Ear House
Surgeon, one Ophthalmic House Surgeon, one Casualt3r Officer, and
one Dental House Surgeon.

At the Bristol General Hospital. — One Senior House Surgeon,
one Casualty House Surgeon, two House Ph3^sicians, one House
Surgeon, and one Dental House Surgeon. All these appointments
are salaried, with board and residence.

For further particulars and prospectus apply to the Dean of the Medical
Faculty or the Pegistrar.

ADVEKTISliMENTS

845

UNIVERSITV OF DURHAM

COLLEGE O F MEDICIHE, HEWOGOTL E-Oll-TYHE.

DKGTIEES in MeBIGINE, SURGRnY AND HYGIENE ; DIPLOMAS IN PUBLIC HEALTH AND Psi’CHIA-
'Jiiy, AND Licence in Dental Surgeby.— Six Degrees, two Diplomas, and one Licence are
conferred by the Giiiversity of Durham— Hs., the Degrees of Bachelor of Medicine, Doctor of
Medicine, iJachelor of Surgery, and Master of Surgery ; Bachelor of Hygiene, and Doctor of
Hygiene ; the Diplomas in Public Health and Psychiatry, and the Licence in Dental Surgery.
These Degrees, etc., are open to Mon and Wonien.

Atteiidance at the University of Durham College of Medicine during one of the five years of
professional study, or subsequently to qualification elsewhere, is required as part of the
curriculuru for tlie Degrees, except in the case of Practitioners of more than fifteen years’
standing, who have attained the age of forty years, who can obtain the Degree of M.D. after
examination only.

The first three Examinations for the Degree of M.B. may be passed prior to the com-
mencement of attendance at Newcastle.

A candidate who has passed the First and Second Examinations of the University will be
exempt from the First and Second Examinations of the Conjoint Board in England, and will
be entitled to present himself for the Final Examination of the Board on the completion of
the necessary curriculum. Students who have satisfied the requirements of the General l\Iedieal
Council as regards Registration, in some Examination other than tlie Durham Matriculation,
or its equivalent, may enter on a course of study for a degree in Medicine upon satisfying the
Examiners of the University of Durham in three of the subjects of the Matriculation
Examination (exclusive of Religions Instruction and Elementary Mathematics), provided that
one of them is a language other than Mnglisli. In the case of a Student who spends only one
year at Newcastle, the necessai'y subjects of the Matriculation Examination must be passed at
least 12 months previously to the candidate’s entry for his Final Examination for the Degree.

Students can complete, at the University of Durham College of Medicine, Newcastle-upon-
Tyne, the entire course of professional study required for tlie above degrees and for the
Diplomas in Public Health and Psychiatry ; also for the examinations of the Royal Colleges of
Physicians and Surgeons, and for the Army and Navy Examination Boards.

A Dental curriculum is provided, and a Licence in Dental Surgery may be obtained after
Examination.

All Information, together with Examination Papers, etc., is given in the Calendar of the
University of Durham College of Medicine, Newcastle-on-Tyne, which may be obtained gratis
from the Secretary at tlie College.

Scholarships, University of Durham Scholarship, value £100 for proficiency in Arts
awarded annually to full students in their first year only. The Pears Scholarship value £150—
for proficiency in Arts. Dickinson Scholarship— value the Interest of £400, and a Gold Medal-
for Medicine, Surgery, Midwifery, and Patlmlogy. Tulloch Scholarship— value the interest of
£400— for Anatomy, Physiology, and Chemistry* Charlton Scholarship— value the interest
of £700— for Medicine. Gibb Scholarship— value the interest of £500— for Pathology. Luke
Armstrong Scholarship— Interest on £(180— for comparative Pathology. Stephen Scott Scholar-
ship-interest on £l(x)0— for promoting the study of Snrgeiw and alllea subjects. Heath
Scholarship— the late George Yeoman Heath, M.l>., M.B., D.u.L., F.R.O.S., President of the
University of Durham College of Medicine, bequeathed the sum of £4000 to found a Scholarship
in Surgerv, the interest to be awarded every second year. Gibson Prize— value the interest of
£225— for Midwifery and Diseases of ^Womon and Children. The Turnbull Prize and Medal—
for Surface Anatomy. The Goydei* Memorial Scholarship (at the Infirmary)— value the interest
of £325— for Clinical Medicine and Clinical Surgery. At the end of each Session, a Prize of
Books is awarded in each of the regular Classes. Assistant Demonstrators of Anatomy. Prosec-
tors, and Assistant Physiologists are elected yearly. Pathological Assistants, Assistants to
the Dental Surgeon, Assistants in the Eye Department, Clinical Clerks and Dressers are
appointed everv three moniihs.

’The Royal Victoria Infirmary contains over 400 beds. Clinical Lectures are delivered by
the Phvsici.ans and Surgeons in rotation. Pathological Demonstrations are given as opnortunity
olTers, by the Pathologist ; Practical Midwifery can be studied nt the Newcastle Maternity
Hospital’, where there is an out-door practice of over 1000 cases annually.

FEES.

[a) A Composition Ticket for Lectures at the College may be obtained—

I. — Bv iiayment of 72 guineas on entrance.

II. — Bv payment of 46 guineas at the commencement of the First Year, and 36 guineas at
the commencement of the Second Year.

III. — By three annual instalments of 36, 31, and 20 guineas respectively, at the commence-
ment of the Se.ssional year.

{b) Fees for attendance on Hospital Practice :— _

For 3 Months’ Medical and Surgical Practice, £6 6s. For 6 months’, £i0 iOs. Fori year’s,
£15 15s, For Perpetual, £36 15s,

Or by two instalments— First year, 20 guineas ; Second vear, 18 guineas.

In addition to the above fees, the Committee of the Royal Victoria Infirmary require
the payment of 2 guineas yearly up to three years from every Student attending the
Infirmary for a year or part of a year. After three years of attendance, such payment
win be no longer necessary.

(d) A Composition Ticket for the courses of Lectm*es and Practical work of the first two years

of the curriculum, may be obtained by the payment of 40 guineas on entrance.

(e) Composition fee for Lectures, etc., at College for Licence in Dental Surgery, 34 guineas;

Composition fee for Practical work at Dental Host>ital, 35 guineas.

if) Composition fee for courses of instruction for the Diploma in Psychiatry, 25 guineas.

Fees for Lectures, etc., at the College and for Hospital Practice, must be paid to the
Secretary ; and fees for Ih’actical Dental Work to the Dean of the Dental Hos^iital- at the ■

^^^^^uvther^particulars may be obtained from the Sec., PROF. HOWDEN, at the College.

ADVERtlSEMENTS

846

ROYAL INFIRMARY,

I N this Hospital (with 921 beds and 42 cots) Clinical Instruction is {?iven by the Professors of the
University of Edinburgh and by the Ordinary Physicians and Surgeons. Three wards are
specialise set apart for the instruction of Women Students. Special instruction is given In
the Medical Department on the Diseases of Women, Physical Diagnosis, and Diseases of tlie
Skin ; and in the Surgical Department on Diseases of the Eye, the Ear, and the Larynx. Separate
Wards are devoted to Venereal Diseases, Diseases of Women, and Diseases of the Eye, the Ear
and Throat, and the Skin ; also to cases of Incidental Delirium or Insanity. Post-mortem Exam-
inations are conducted in the Anatomical Theatre by the Pathologist, who also gives Practical
Instruction in Pathological Anatomy and Histology.

MEDiCAL DEPARTMENT,

Consulting Physicians— Sin James Aeeleck, Dk. Alexander James, Dr, Byrom Bramwell,
Emkr..Prof. W. S. Grbeneield.,

Physicians— Sir Thomas R. Fraskr, Professor of Materia Medica, Edinburgh University,
Dr. John Wyllie, Professor of Medicine, Edinburgh University ; Sib R. W. Philip, Senior
Lecturer in Clinical Medicine, Edinburgh University ; Dr. William Russell, ProfesKor of
Clinical Medicine, Edinburgh University ; Dr, Lovell Gulland, Dr. Graham Brow'-n, Dr. P,
D. Boyd, Senior Lecturers in Clinical Medicine, Edinburgh University ; Dr. R. A. Flkming.
Assistant Physicians— Dr. Harry Rainy, Dr. Chalmers Watson, Dr. Edwin Bramwt2ll,
Dr. Edwin Matthew, Dr. W. T. Richie, Dr. John Eason, Dr. John D. Comrie, Lecturers in
Clinical Medicine, Edinburgh University. (One Vacancy).

SURGICAL DEPARTMENT.

Consulting Surgeons— Mr, A. G. Miller, Dr. C. W. MacGilli^-ray, Emer.-Prop. John Chiene,
G.B., Mr. J. M. Cotterill,

Surgeons— Mr. E. M. Caird, Regius Professor of Clinical Surgery, Edinburgh University ; Mr. C.
W, Oathcart, Mr. J.W. B. Hod.sdon, Mr- David Wallace, Senior Lecturers in Clinical Surgery,
Edinburgh University; Mr, Alexis Thomson, Professor of Systematic Surgery, Edinburgh
University; Mr. Alexander Miles, Senior Lecturer in Clinical Surgery, Edinburgh Univer-
sity ; Mr. John W. Dowden.

Assistant Surgeons— Mii. A. A. Scot Skirving, Mr. George L. Chiene, Mb. W. J. Stuart,
Mr. j. W. Struthers, Mr. Henry Wade, Mr. E. Scott Carmichael. Mr. D. P. D. Wilkie,
Mr. L. C. Peel Ritchie, Mr. Denis Cotterill, Lectrs. in Clinical Surgery, Edin. University.

GYNAECOLOGICAL DEPARTMENT.

Consulting Gynsscologists.— Prof. Sir Halliday Croom, Emeritus-Prof. Sib A.R. Simpson.
Gynaecologists— Dr. A, H. F. Barbour, Mr. N. T. Brewis, Lecturers in Clinical Gymecologj^
Edin. University.

Assistant Gynaecologists— Dr. J. Haig Ferguson, Dr. William Fobdyce, Lecturers in Clinical
Gynaecology, Edinburgh University.

DEPARTMENT FOR DISEASES OF THE SKIN.

Consulting Physician -Dr. W. Allan Jamieson.

Physicians— Dr. Norman Walker, Dr. Fred Gardiner, Lecturers in Dermatology.

Assistant Physician— Dr. R. Cranston Low.

OPHTHALMIC DEPARTMENT.

Consulting Surgeons— Mr. George A. Berry, Dr. George Mackay.

Surgeons— Dr. W . G. Sym, Dr. J. V. Paterson, Lecturers in Ophthalmology,

Assistant Surgeons— Dr. A. H. H. SiNCL.mi, Dr. H. M. Traquair.

EAR AND THROAT DEPARTMENT.

Consulting Surgeons— Dr. P. M’Bride, Dr. B. M’Kenzie Johnston.

Surgeons— Dr. a. Logan Turner, Dr. J. Malcolm Farquharson, Lectrs. in Ear & Throat Diseases.
Assistant Surgeons— Dr. John S. Fraser, Dr. John D. Lithgow.

DENTAL DEPARTMENT.

Consulting Surgeon— Mr. William Guy. Surgeon— Mr. J. H. Gibh.s.

ELECTRICAL DEPARTMENT.

Extra Medical Electrician (/or Radium Oases)— J>s.. Dawson Turner.

Medical Electricians— Db. W. Hope Fowler, Dr. Archibald M’Kendrick.

PATHOLOGICAL DEPARTMENT.

Consultant Pathologist— Professor Lorrain Smith. Pathologist— Dr. Theodore Shennan,

Assistant Pathologists— Db. James Miller, Dr. A. Murray Drennan, Dr. D. Murray Lyon.
Superintendent— Lieut.-Col. Sir Joseph Fayrer, Bart., m.d., f.r.c.s.

Hospital Tickets.— Perpetual Ticket, in one payment, il2 ; Annual Ticket, JBB 6s. ; Six Months,
£4 4s.; Three Months, ^3 2s.; One Month, £1 Is. Separate payments, amounting to £12 12s.,
entitle the Student to a Perpetual Ticket on production of previous Season Tickets.

APPOINTMENTS.

No fees are cimrgedfor any Medical or Surgical Appointments in this Hospital, lohich are asfoUoiPS :

1. Kesident Physicians and Surgeons, who must be registered as legally qualified Practitioners,
are from time to time appointed by the Managers on the recommendation of the Physicians and
Surgeons. The holders of these offices live in the house free of charge. The appointment is
for six months, but may be renewed at the end of that period by special recommendation.

2, Non-Eesident House Physicians and Surgeons or Clinical Assistants, who must also be regis-
tered as legally qualified Practitioners, are appointed by the Managers on the recommendation
of the Physicians and Surgeons, The appointment is on the same terms as that of the Ptesident
Physicians and Surgeons.

3, Clerks and Dressers are appointed by the Physicians and Surgeons. These appointments
are open to all Students and Junior Practitioners holding Hospital Tickets.

Assistants in the Pathological Department are appointed by the Pathologist.

WILLIAM 3. CAW, Treasurer and Clerk,

ADVERTISEMENTS

847

UNIVERSITY OF EDINBURGH.

SESSION 1913-14.

PHwcijjaZ— Sir WILLIAM TURNER, K.C.B., L.C.L., LL.D„ D.Sc., M.B.

The WINTER SESSION opens on the 7th. of October, and closes 18th March.
The SUMMER SESSION opens on 15th April.

FACULTY OF MEDICINE.

DeaM-PROFES-soii HARVEY LITTLEJOHN, M.A.. B.Sc., M.B., C.M.

The, Faculty embraces thirteen Chairs and twenty-one Lectureships; and attached to
these Chairs there are about thirty assistants and Demonstrators. Instruction is given in all
the main branches of Medical Science, vis.,

PROFESSORS.

Chemist7^—J&mes Walker, D.Sc., F.R.S.
Zoology— Oossar Ewart, M.D.

JSot/iity— Isaac Bayley Balfour, M.D., D.Sc.
.4«a<om2/— Arthur Robinson, M.D., C.M.
Physiology— E. A. Schafer, LL.D.

Materia Medico— Sir Thomas B. Fraser, M.D.
LL.D,

Pathology—S. Lorraln Smith, M.A., M.Dr
Forensic Medicine— B.&vvey Littlejohn, M.B.,
B-Sc.

PnhUe Health— C. Hunter Stewart, M.B., D.Sc,
Mcd/ciae— John Wyllie, M.D., LL.D.
f^urgcry— Alexis Thomson, M.D., C.M., B.Sc.
MiihvifeniSir J. Halliday Croom, M.D.
Clinical Surgery — Francis Mitchell Caird, M.B ,
C.M.

Clinical 3IedicbteSli' Thomas R. Fraser, M.D.
John Wyllie, M.D.

UNIVERSITY LECTURERS.

Mental Clsease^-ri^eoi'ge M. Robertson, M.B.,

c.m: ■ ^

Diseases of the Fye—WilUani G. Sym, M.D.
Systematic and Clinical Qynacology—

' A. H. F, Barbour, M.A., M.D.

Clinical Instruction on Diseases of Children—

D.Qc.

Anatoi^—'E. R. Jamieson, M.D., and T. B,
Johnston, M.B., Ch.B.

Ajiplied Anatomy— Knrold J. Stiles, M.B., C.M.
Mistology’^PLaxold, Pringle, M.D.

Physiological Chemistry— W . Cramer, Ph.D.,
*• D.Sc.

Experimental Pltysiology — John Tait, M.D.,
D.Sc.

Experimetital Phannorcology—W. C. Sillar, M.D.,
B.Sc.

Physics— C, G. Enott, M.A., D.Sc.

Pathological Bacteriology— E. Carnegie
Dickson, M.D,, B.Sc.

Diseases of the Larynx^ Ear and Nose— A. Logan
Turner, M.D.

Tropical Diseases— D. G. Marshall, Major, I.M.S.

Medical Entomology^ and Protozoology— I » H.
Ashworth, D.Sc.

Tropical Hygiene— I , B. Young, M.B., D.Sc.,
conjointly with Professor.

Diseases of tfie Skin— Norman Walker, M.D.,
and Frederick Gardiner, M.D.

Clinical Instruction in Infectious Fevers—
Alexander James, M.D. ; Claude B.Ker.M.D.

History of 3IcdiciHe—3 . D. Comrie, M.A., B.Sc..
M.D,

Neurology— J. J. Graham Brown, M.D.

Physical Methods in the Treatment of Disease-
Hairy Rainy, M.A., M.D.

Practical Anaisthetics~D. C, A. MeAlliim, M.B.,
C.M., Demonstrator.

Practical Instruction is afforded, under the superintendence of the Professors, In Labora-
toriefi with the necessary appliances, and in Tutoriai and Practical Classes connected with the
above Chairs, and opportunities are afforded to Students and Graduates to extend their
practical knowledge and engage in original research. , ^

Opportunities for Hospital Practice are afforded at the Royal Infirmary, the Hospital for
Sick Children, Maternity Hospital, the City Fever Hospital, and Asylum for the Insane. Up-
wards of 2,160 beds ai’e available for the Clinical Insti'uetlon of Students of the University.

Four Degrees in Medicine and Surgery are conferred by the University of Edinburgh, viz.,
Bachelor of Medicine {M.B.), Bachelor of Surgery (Ch.B.), Doctor of Medicine (M.D.>, and Master
of Surgery (Ch.M.) ; and Diplomas in Special Branches of Medical and Surgical Practice may
also be conferred on Graduates in Medicine and Surgery of tlie University.

The minimum Class Fees for INE.B. and Ch.B., including Hospital Fee (£12), amount to about
£130, and the Matriculation and Examination Pees to £28 7s.' An additional I’ee of £15 15a. is
payable by those who proceed to M.D.,and £15 15s. by those who proceed to Ch.M,

The Annual value of the Bursaries, Prizes, Scholarships, and Fellowships in the Faculty
of Medicine amounts to about £3,600, and that of the other Bursaries, etc., tenable by students
of Medicine, amounts to about £1,820. ,

Instruction is also given in Public Health, and the Degrees of B.Sc. and D.Sc. in Public
Health are conferred by the University.

Residences for Students, Graduates and others, situated within easy reach of the University,
afford excellent board and lodgings on very moderate fceims. « -

A Syllabus and further information as to Matriculation, the Curricula of Study for Degrees,
etc., may be obtained from the Dean of the Faculty of Medicine, and for Degrees in the Faculties
of Arts, Science, Divinity, Law and Music, from the Deans of these Faculties; or from the Clerk
of Senatus; and full details are given in the University Calendar, published by James Thin,
55, South Bridge, Edinburgh. Price by post, 3s. 6d. -

The Preliminary and Degree Examination Papers in each of the Faculties are also publishea
by Mr. James Thin— viz., Arts and Science Preliminary Papers and Bui'sary Papers. Is.; Medical
Preliminary Papers, 6d. ; Degree Papers— Arts, Is.; Science, 9d.; Divinity, Law', Medicine, and
Music, 6d. each.

October, 1913.

By Authority of the Senatus,

L. J. GRANT, Secretary of Senatus.

ADVJSRTISEMENTS

Plaistow Hospital,

LONDON, E.

INSTRUCTION IN FEVERS, Ac.

'^HIS Hospital has been rebuilt and fully equipped for instruction
in Infectious Diseases. It is recognized by the Universities of
London, Cambridge, and Oxford, the Royal Colleges of Physicians
and Surgeons, etc.

1. — Classes for Medical Students are held on Tuesdays and Fridays
throughout the year, except in April, August and September. There is a
Morning Class at 10.45, and an Afternoon Class .at 2.15. Fee for a two
months' course, 3 guineas : for a three months’ course, 4 guineas. In the
event of there being Small-Pox cases at Dagenham Hospital during the
Students’ Course, instructions in that' disease will be included.

II. — A three riionths’ D.P.H. Course begins in October, January, and
May. Lectures on Hospital Construction, Equipment, and Administration
are included in this course. For Fees, apply as below.

Enquiries and Applications to join the, above courses should he addressed to

Dr. BIERNACKI, Physician Superintendent, Plaistow Hospital, E,

The Superintendent can also be seen at the Hospital on weekdays at 2 p.m.

Th|B Hospital Is situated near Upton Park Station, to which frequent Trains run on
the District and London and Tilbury Railways.

UNIVERSITY COLLEGE OF SOUTH WALES and
lyiONIVIO UTHSHIRE, CARDIFF.

FACULTY OF MEDICINE.

Stuileiits may spend at least thi'ce out o( the live yeavs of IheiL* medical study at this Golloiie. The
eouL'sesuf insti’uction tilvcii are recognized as qualifying for the Examinations of the Universities, Itoyal
Colleges, and other licensing bodies of Great Uritaiu and Ireland. ^ledical men preparing for a Diploma
In 1‘ublic Health and Hygiene can attend complete courses of instruction in these subjects. All classes
are open to Women Students. The coinposiliou fee for sLudeiits preparing for the first and second
examinations in Medicine of the University of Ix>ndoii is The composition fee for the classes

qualifying for the first and second examinations of the Conjoint hoard is Ml 10s, The composition fee for
the D.IMT. Course is i:3i0. Hospital instruction may be taken at King Edward VIl's Hospital, which is
situated within three minutes’ walk of the College. A course of Lectures to Midwives adapted to the require*
meats of the Cei\tral Midwives hoard, under the Midwives Act, was commenced in October, 1004. The Lec-
tures are suitable both for hupil-Midwlvos and Practising-Midwlvos, as well as for Nurses who desire to
enter for tiie Examination for Certiftcauion under the Act. A prospectus containing all information regard*
iug classes, fees and entrance scholarships may be obtained by application to the llegisbrar of the College.

P/ij/nies. . Vrof. A. L. Selhy, M. A., assisted by J. H. Shax*
by, B.Sc., A.Il,O.S., and H. T. Elint, M.Sc.
C/i«i«is<ri/..Prof. C. M. Thompson, M.A., D.Sc., P.C.S.,
assisted by Assist.-Prof. E. P, Permau, D.Sc.,P.C,S.,
and llobert D. Abell, D.Sc., Ph.D., IM.C,, F.C.S.
JSfiwk'gl/. .Prof. W. N, Parker, Ph.D,, F.Z.S., assisted by
Margaret Latarcbe, M.hc.

2li)/‘jUi}/,.Prof. A. H, Trow, B.Sc., P.L.S., assisted by
W. O. Howarth, IJ.Sc,

A mtlomy. Prof. David Hepburn.V.B,,:!!.!).. C.M., P.Il,S.
Ed., assisted by 1). Leighton Davies, M.D-, M.S.
(Lond.), F.I1.C.S., & Jas. 0. D. Wade, M,h. (Lond.)
M.S., F.E.C.S.

Physiological Chemistry—M. H. Benall, B.Sc.
PhysMogy—Pvot. John Berry Haycraft, M.D., D.Sc.,
F.ILS.E., assisted by M. H. Henall, B.Sc.

HUtolagy a»d Embryology., 'll. H. Burlend, M.A,, B.Sc.
Materia Medica tfe Pharmacology.. "VI. Mitchell Stevens,
M.B„ M.ILC.P., M.E.C.S.

Pathology and Jtaeteriology.,'Btot. E. Emeys-Boherts,
M.D., M.B., Ch.B.

Vaecinaiton—Vrot, E. Emr ys-Hoberts, M.D., M.B.,Ch.B.
Public llmlth and Myoiem.. Edward Walford,
D.P.H.. and D. J. Jlorgan, M.A., M.D., D.P.H.
Hygienic CliemiHtvu..3. H. Sugden, M.Sc., F.I,C.
Midicifery (for M((fNiirr8)..E. J.MacIean,M.D.,M.tt.O.P.
D. J. A. BROW’N, Hkgistuar of thr Cor.t.EGE. F.R.S.E.

DAVID HEPhUhN. V.D.. M.D., C.M., P.Il.S.E., Dean of the Faculty of Medicine.

St. John Ambulance Association

INVALID TRANSPORT SERVICE.

(Under the patronage of many leading physicians and surgeons), for the
Conveyance of Sick and Injured Patients (infectious cases excepted) to and
from all pai-ts. The Association has a fully trained staff and all necessary-
appliances. — For particulars apply to the TRANSPORT MANAGER, St.
John’s Gate, Clerkenwell, London, E.C.

Telegrams: “Firstaid, London.”' Telephone; 861 Holborn,

ADVERTISEMENTS

849

T^ y p .

UNIVERSITYof LIVERPOOL

FACULTY OF MEDICINE.

The University grants degrees in Medicine, Surgery, Hygiene, and Dental Sur-
gery, and Diplomas in Public Health, Tropical Medicine,* Dental Surgery, Ophthalmic.
Surgery, Anatomy, Bacteriology, Bio-chemistry and Parasitology.

Students may also prepare in the University for the examinations of other
licensing bodies

Medical School Buildings . — The buildings of the Medical School are all modern,
and contain spacious lecture rooms, and well-equipped laboratories and class-rooms
for the study of all the more important subjects which form the basis of medicine.
In addition, laboratories are provided for medical research in Bio-chemistr3%
Tropical Medicine, Physiology, Pathology, and Bacteriology.

Hospitals Clinical School consists of four general hospitals — the Royal
Infirmary, the David Lewis Northern Hospital, the Royal Southern Hospital, and
the Stanley Hospital ; and of five special hospitals : the Eye and Ear Infirmary,
the Hospital for Women, the Infirmar^j- for Children, St. Paul’s E\*e Hospital, and
St. George’s Hospital for Skin Diseases. These hospitals contain in all a total
of 1127 beds.

Fellowships and Scholarships — Fellowships, Scholarships, and prizes of over £900
are aw'arded annually. There are also numerous Entrance Scholarships. Particulars
may be obtained on application.

TJte following jprosj^eciuses may he ohtainea oit a^j>Hcaiion to the Registrar: — Medical
Faculty, School of Tropical Medicine, School of Dental Surgery, and School cf
Veterinary Medicine,

K. W, MONSARRAT, M.B.. C.M., F.R.C.S. Dean,

CHARING ^ HOSPITAL

MEDICAL school,

(UNIVERSITY OF LONDON).

The most central and easily accessible of all the Colleges of the University, and situated within
four minutes' walk of the University Laboratories (King's College).

Its close proximity to the University Laboratories enables its Students to obtain the
best Scientific Education in their Primary and Intermediate Studies, while still allowing
them to use their School Library, Club Rooms, &c., for Study and Social purposes.

For the purposes of its Final Studies, the School now posse.sses most commodious LABORATORIES,
Special I.ABORATORIES having been set aside for purposes of Post-Graduate Study and Rese.arch.

For Prospectus and full information apply personally or by letter to the Dean,

WILLIAM HUNTER, xM.D., F.R.C.P., Bean.

UNIVERSITY OF MANCHESTER

FACULTY OF MEDICINE.

C urriculum. — C omplete courses of instruction are offered to Students
(Men and Women) preparing for Degrees in Medicine and Surgery, and in
Science, for Degrees and Diplomas in Public Health and Dentistry, and for
Diplomas in Veterinary State Medicine, Psj'chological Medicine and Pharmacy,
and for the Qualifications of the Conjoint Board and other Licensing Bodies.

The Universit}’- contains spacious and well-equipped Laboratories and Museums
in all departments of Science and Medicine. For Women Students a separate
Laboratory for Practical Anatomy and Special Common Rooms are provided.

The Prospectus of the Medical Faculty and the special Prospectuses for the
following departments: Dental, Public Health, and Pharmaceutical, will be
forwarded on application to the REGISTRAR.

S50

A D VERT ISE MEN TS

ROYAL EYE HOSPITAL,

London School of
Ophthalmic Surgery
and Medicine.

ST. GEORGE’S CIRCUS, SOUTHWARK, S.E.

Surgreons :

Sir W. J. Collins, K.V.O.O., M.D., M.S., B.Sc. (Loud.), F.R.C.S. ; L. Vernon Cargill,
F.E.C.S. ; G. Brookshank James, F.R.C.S. ; H. Willoughby Lyle, M.D., B.S. (Lond,),
F.R.C.S.; J. Stroud Hosford, F.R.C.S. (Edin.)

Assistant Surg^eons :

A, D. Griffith, M.B., B.S. aond.), F.R.C.S. ; E. Arthur DorreU, F.R.C.S,
Physician : James Collier, M.I)., B.Sc. (Loud.), P.R.C,P.

Dean ; A. 3>. Griffith, F.R.O.S.

Lectures^ Demon.strations, Instruction in Refraction work, and Demonstrations on Patho-
loja;ical Specimens in the Museum are given throughout the Winter and Summer Sessions by the
Teaching Staff of the Hospital. Clinical instruction is given daily in the Out-patient department
at 10 a.m. and 3 p.m. There are annually upwards of pi, 000 oiu-patienis attending the

Hospital. There is therefore ample opportunity for Practitionei s and Medical Students, to acquire
a thorough practical knowledge of Ophthalmology. ftiriher particulars ajipiy to the Deatu

Richmond, Whitworth and
Hard wicke Hospitals,

DUBUN.

T he session 1913-14 commenced on October 1st, 1913. These
Hospitals for Surgical, Medical, and Fever Cases respectively, contain
nearly 300 beds.

Physicians: Doctors O’Carroll, Coleman, and Travers-Smith. Assistant Physicians: Doctors
Matson and Ne.sbitt.

Surgeons: Sir Thomas Myles, Mr. R. J. Harvey, Mr. Conway Dyer. Assistant Surgeons:

Mr. Slattery, Mr. McConnell, Mr. Crawford.

X Rayist: Mr. Crawford-.

Ophthalmic Surgeon : Mr. Joyce. Gynaecologist : Dr. Gibson.

Laryngologist ; Dr. Gogarty. Pathologist : Dr. Earl.

Anaesthetist : Dr. Boyd. Dentist : Mr. Bradley,

Unqualified re.sident clinical clerks are appointed quarterly from any lecognised school of medicine.
Far Particulars apply :

R. Traveks-Smith, M.D., 6i, Fitzwilliam Square, Dublin, Hou. See, and ’Jrensurcr.

THE PARAGON

Medical and Educational Gymnasium and
School of FeUClng

A First-class Private Institute for the Improvement of
the Physique in Structure and Function by Exercise,

Jh ^ Massage and Electricity. ^ ^

HIGHLY RECOMMENDED BY THE MEDICAL FACULTY.

Mn PERCIVAL C. COTTLE,

12 Paragon, BATH.

ADVERTISEMENTS

St. ANDREWS UNIVERSITY

FACULTY OF MEDICINE.

The Session 1913-14, commenced OCTOBER 7th, 1913.

The whole Curriculum may be taken in Dundee, or the first two years of the Course may he
taken in St. Andrews, and the remaining three years in the Conjoint School of Medicine, UniversitN’
College, Dundee. The various laboratories are fully equipped for teaching and for research.

CDINICAD INSTRUCTION is given at the Dundee Royal Infimiarj’, which has 400 beds,
with special wards for Maternity cases. Diseases of Women, Diseases of Children, Diseases of the
Eye, Diseases of the Ear, Throat, and Nose, Diseases of the .Skin, Cancer, Incipient Insanity, and
for cases requiring electrical tr^tment ; also instruction in Diseases of the Eye is given at the
Dundee Eye Institution, which is attended by over 4000 patients annually. Clinical Instruction
in Fevers is given at the Municipal Fever Hospital : and Clinical Instruction in IMental Diseases
at the Dundee District Asylum, which has about 400 resident patients.

APPOINTMENTS^. — Six Resident Medical Assistants, and an Outdoor Obstetric Assistant
are appointed annually at the Dundee Royal Infirmary. At the District Asylum the appointments
include two qualified Resident Medical Assistants and two Resident Clinical Assistants.

BURSARIES. — At United College, St. Andrews, two Malcolm Medical Bursaries of the
annual value of £25 and tenable for five j-ears, are open to meu or women. Nine Taylour-
Thomson Medical Bursaries of the annual value of £15 to £25, are limited to women. At
University College, Dundee, tw'elve Entrance Bursaries of the value of £15 each, and fourteen
Second and Third Year’s Bursarie.s of the value of £20 and £15, are open to competition. Two
Fourth and two Fifth Year’s Bursaries of £20 each are open to Students who take the Complete
Curriculum in University College. Other Bursaries, of which the patronage is vested in trustees,
are available.

THE FEES for the Complete Course, exclusive of Examination Fees, amount to about £130.
For further information, apply to the Secretarj’, at St. Andrews, or to

. PROFESSOR KYNOCH, Dean.

Conjoint School op Medicine, Dundee, October, 1913.

UfllVERSITY of ABERDEEN

rjflLOXJZ-T^Sr 03P 3VIE5I>IOI3WaES.

rpHE Degrees in medicine granted by the University are~Bachelor of Medicine, Bachelor of Sur-
gery, Doctor of Medicine, and Master of Surgery; They are conferred only after Examination,
and only on Students of the University. Women are admitted to instruction and graduation
on the same footing as men. A Diploma in Public Health is conferred after Examination on
Graduates in Medicine of any University In the United Kingdom.

The Faculty of Medicine embraces twelve chairs, from Yvhich instruction is given in all the main
branches of Medical Science.

Ih’actical Classes in connection with these chairs are conducted by the Professors and Assistants
In Laboratories furnished -with all the necessary appliances; and opportunities are afforded to
Students and Graduates to extend their practical knowledge and engage in original research.

Instruction is also given in special departments of Medical Practice by Lecturers appointed by
the University Court.

Clinical instruction is obtained in the Royal Infirmary, Royal Lunatic Asylum, the Sick
Children’s Hospital, the City (Fever) Hospital, the General Dispensary, Maternity Hospital
and Vaccine Institutions, and the Ophthalmic Institutions.

Bursaries, Scholarships, Fellowships and Prizes, to the number of 50 and of the Annual Value of
£ 1183 , may be held by Students in this Faculty.

Tile cost of Matriculation, Class and Hosijital Fees for the whole curriculum, inclusive of the
fees for the Degrees, is usually about £ 1 ®),

A Prospectus of the Classes, Fees, &c„ may be had on application to the Secretary of the
Faculty of Medicine.

J. THEODORE CASH, M.D., LL,D„ F.R.S., of Medieal Faeultu.

l{oyal College of Surgeons of Edinburgh

FOUNDED 1505.

Copies of the Regulations for the Fellowship, Licence, and Licence in
Dental Surgery, with dates of Examinations, Curricula, etc., for the year
1914, are now ready, and may be bad on application to —

D. L. EADIE, 54, George SguARE, Edinburgh, Clerk to the College.

85 ?.

ADVERTISEMENTS

HOME STUDENTS COLLEGE Ltd., CAMBRIDGE.

For the Direction of Private Study.

principal: R. W LUMMIS, M.A. (Oxford and Cambridge), King’s College.

T his College gives to the Home Student all the guidance needed in beginning and
mastering any branch of study, whether it be undertaken for culture, for an
examination,’ or for technical or professional purposes.

The Unh'ersity of Cambridge has resident specialists in all departments of learn*
ing. The College is thus able to draw upon the highest knowledge and skill for the
particular requirements of any student whatsoever, to save useless expense and mis-
directed toil, to ensure that every hour of study shall tell, and that the knowledge
gained is abreast of the latest discoveries.

The Homo Student who joins the H.S.C. has an immense advantage over one,
However earnest, who tries to “muddle through” without expert guidance.

Write to the Principal, i, Rose Crescent, Cambridge,

MEDICAL CORRESPONDENCE COLLEGE,

la, WnPOLE STREET, aVENDISH SQUARE, LONDON, W.

Large staff of highly-qualified Tutors, Honoursmen, and Gold Medallists.
Free Guide to Medical Examinations on application.

REGENT REMARKABLE SUCCESSES

M.D.Lond. and other Universities,
successes obtained in 1910-13.

M.D. Thesis. — Skilled Coach ing
and guidance by Specialist Tutors in
conformity with the Regulations of
the various Universities.

M.p.Ed[in., 1913, — 8 successful,
including Gold Medallist.

M.D. Brttx. — Last 5 successes all
obt lined distinction-

F.R.G.S. Eng. — 15 successes, 12
at first attempt.

F, R, C. S. Edin. — Coaching by
Tutors with special experience of the
Exam.

R.A.M.G., July, 1913. — Two of the
five successful candidates were coached
at this Institution, including the first
on the list.

M.S. Lond. — Special Course by an
M.S. Lond. (Gold Medallist).

M. R. G. S., L. R. G. P. - Short
Postal Revision Courses one month
before each Exam. At a recent Exam.
5 sent up for Conjoint Surgery ; all
successful.

D. P. H. — Laboratory instruction
can be commenced at any time.

REGENT NOTEWORTHY SUCCESSES

R.A.M.G.; Jan., 1912. — 1st place
(bracketed), July, 1913, 1st place.

I.M.S., Jan., 1913.-— 7th place.

F.R.G.S, (Primary) . — The first
lady candidate.

R.A.M,G., R.N., & I.M.S.—

Highly successful Revision Courses
for these Exams,

Diploma in Tropical Medicine (Conjoint). — The first successful candidate.

Oral and Practical Coaching can be arranged for any Examination.
Apply for Prospectus and full particulars to the Secretary, as above.

Kent AGRICULTUBAL SCHOOL

seuindge:, htthe.

Specially adapted for Boys 33 to IS, Requiring Open-air Life, or
Individual Attention. General School Subjects, Agriculture, etc.
Liberal Diet, Healthy Country, near Sea, Prospectus on Application.

FREDK. JENKINS, B.A. Cantab.

NOTICE to ADVERTISERS. Advertisements for insertion in the “ MEDICAL
^ ANNUAL” should be sent to the Publishers:

JOHN WRIGHT & SONS LTD., BRISTOL

ADVERTISEMENTS

The Hospital for Sick Children

GREAT ORMOND STREET, W.G.

Clinical Instruction is given daily by Members of the Visiting Staff in the
Wards, Out-patient Department, Operating Theatre and Post-mortem Room.

Clinical Clerkships in the Wards and Clinical Assistantships in the Out-
patient Department are also available for Students and Post-Graduates.

During each Session, Classes are held on Special Subjects, by Members of
the Staff, Fee for a course of Six Meetings, £1 Is.

Fees for Hospital Attendances : — One Month’s Ticket, £2 2-s. Three
Months’ Ticket, £5 5s. Perpetual Ticket, £10 10s.

Special Reduced fee for Clinical Clerks for 3 months, £1 ls»

On Tuesdays and Fridays, from 5.15 to 6.15, a special Course of Instruction
in the Surgical Diseases of Children is given throughout the year. Fee for
8 attendances, £1 Is.

Pathological Clerkships. — Facilities are afforded for obtaining Theoretical
and Practical Instruction in Clinical Pathology and Bacteriology in the
Pathological Laboratories. Clerks attend for about four hours daily. Fees : —
For 1 month, £3 3s. For 2 months, £5 5s. For 3 months, £6 6s.

A reduction is made in the case of those already holding tickets for general
attendance at the Flospital.

From time to time, during each term, special courses of instruction in the
Medical and Surgical Diseases of Children are given, extending over a period of
three weeks. During the Autumn Session a special course of Post-Graduate in-
struction is held for a period of a fortnight. Details are published in the medical
journals during the month of Septembei^ Further particulars may be obtained
from the Secretary or the Dean,

Signed, GEORGE E. WAUGH, F.R.C.S., Dean to the Medical School*

University Examination Postai

Institution.

OSiicess 17, RED LION SQUARE,

HOLBORN, LONDON, W.C.

Manager: Mr. E. S. WEYMOUTH, M.A. (Lond.)

POSTAL or ORAL PREPARATION
Sor ALL MEDICAL EXAMINATIONS.

SOME REGENT SUCCESSES.

M.D. (Lond.), 1901-13: 197, including 10 Gold Medallists.

M.S. (Lond.), 1902-13 : 16, including 3 Gold Medallists.

Second Medical (Lond.), 1906-13: 17.

M.B., B.S. (Lond.), T906-13 : 55, besides others who have only tried one
M.R.C.P. (Lond.), during 1906-13: 20. [group as yet.

D.P.H., 1906-13 : 111. Laboratory work always in progress,

F.R.C.S. (Eng., Edin., Irel,) : 38. P.R.C.S. (Eng.). Nov. 1912 E.xam. : 6.

PRIMARY P.R.C.S, (Eng.), 1906-13 : 39.

R.A.M.G. Entrance, Jan. 1912: 3 placed.

Promotion to Major, R.A.M.G. 1906-13 : 22. No failures for this examination.
GONJOINT FINAL, 1906-13: 32 (besides 10 who tried part only).
M.D. Brux., 1910-13 : 20, including several with distinction.

M.D. Durham: Of the last 14 candidates, 12 succeeded.

M. D. (Thesis) : Numerous successes at various Universities. Legitimate

assistance.

N. B. — There are different modes of counting “successes.’’ The figures given do not include
successes gained by private pupils of the Tutors. List of 20 years successes sent on application.

85-1

ADVERTISEMENTS

DEXTRA DARE.

n^eaical Defence Union,

INGORPORATBD I&S5. LIMITED.

4 Trafalgar Square, Strand, W.G.

Pieshie7it: 1 Hon. 'Fi-casureri

KDGAR BARNES, M.D., J.P. | F. J. WETHERED, M.D., F.R.C.P.
Ge/ict-al Seaeia^y: A. G. BATEMAN, M.B.

THE OBJECTS OF THE UNION ARE AS FOLLOWS:

I*— To support and protect the character and interests of Medical Practitioners
practising in the United Kingdom,

II.— To promote honourable practice, and to suppress or prosecute unauthorised
practitioners.

III.— To ADVISE and DEFEND or assist in defending Members of the Union incases
where proceedings involving questions of professional principle or otherwise
are brought against them.

T he subscription at present islOs. per a.nnum, and an Entrance Fee 0^108*5

and each member has also to guarantee a certain sum (not less than ii) which forms the
extent of his liability. The Subscription becomes due on January ist of each Year.

The Guarantee Fund exceeds £11,000, and is available should any occasion
require its being called up, but up to the present time all claims for administration, legal, and
other costs have been defrayed out of the annual income.

E.xecutive, Committee, or Council Meetings are held at the Registered Offices every weeh,
and cases of emergency are dealt with as they arise.

Application Forms, Copies of last Report, and any other information can be obtained by
applying to the Secretary at the Registered Offices.

A. G. BAl'EMAN, General Secretary^

7 Manchester Medical Agency Ltd.

9 ALBKRT SQTTARB.

Telegrams’ “MEDICO, MANCHESTER," Telephone: Central 4800.

Secretary: CHARLES STEVENSON, F.C.I.S.

Prompt 6t Personal Attention to the Requirements of all Clients.

RIBBY LINE —

to Egypt, Ceylon & Burma.

Only FIRST-CLASS Passengers Carried.

Full set of Instruments and Drugs supplied.

Length of Voyage - about 2i months.

SURGEONS DESIRING APPOINTMENTS

should apply to BIBBY BROS. & CO.,

10/11 Mincing Lane, LONDON, E.C„ or 26 Chapel St. LIVERPOOL.

A 0 VERTISEMEN Ta

855

The London and Counties
IVledical Protection Society,

FOUNDED IN 1892 LTD.

Registered Offi ces: 52 Craven Stree t, strand, W.C.

Telegrams : Telephone :

“ MEDICA.VERO WESTRAKD, LONDON.’* 5098 CENTRAL

President :

GEO. A. HERON, M.D.. F.R.C.P.

Trustees for Reserve Fund:

Sir R. DOUGT.AS POWELL. Bart.. KC.V.O., M.D.. F.R.C-P.

Sir JAMES REID, Bart., G.C.V.O., K.C.B.. M.D.. F.R C.P.

Sir JOHN TWEEDY, LL.D., F.R.C.S.

Treasurer :

C. M. FEGEN. M.R.C.S., D.P.H.

Vice-Chairman of Council:

E. C. BENSLEY, F.R.C.S.

Deputy Vice-Chairman of Council:

C. M. FEGEN, M.R.C.S, D.P.H.

General Secretary : Financial Secretary :

HUGH WOODS. M.D.. B.A. A. G. R. FOULERTON, F.R.C.S.

Among the principal objects of the Society, as defined in the

Memorandum of Association, are the following: —

a. To protect, support, and safeguard the character and

interests of legally qualified Medical and Dental Practi-
titioners, and

b. To advise and assist members of the Society in matters

affecting their professional character and interests.

The subscription to the Society is ;:^*1 per annum, with an entrance
fee of 10s. A member of the Society is indemnified against all
costs incurred on his behalf in any case in which the Society has
decided to act for him ; he is also, subject to the Articles of
iVssociation, indemnified to the extent of £2fi00 in any one year,
against costs of the other side and any damages which may follow
an adverse decision, provision being made for this purpose of an
available sum of ;^'22,000 per annum.

The Reserve Funds of the Society as on 31st December, 1912,
amounted to a sum of ;^9,343, and in addition to this amount the
Guarantee Fund of the Society represents an amount of more than
/4,830.

Forms of Application for Membership and full particulars can be obtained from the
Secretaries, 32, CRAVEN STREET, STRAND, LONDON, W.C.

ADVERTISEMENTS

STAMMERING PERMANENTLY

Resident and Daily Pupils received throughout the Year.

LBTTBRS RBCBIVBD FROM ALL PARTS OF THE WORLD.

PROVE THAT UNIVERSAL SUCCESS HAS BEEN ATTAINED.

PAST PUPILS

include Military and Naval Officers, men from Oxford and Cambridge,
sons of Doctors, Solicitors, and others of good social standing.

Prospectus with Testimonials Post Free from

Mr. A. C. SCHNELLE, 119 Bedfonl Court Mansions, London, W.C.

ESTABLISHED 1905.

STAMMERING TREATED

By Mrs, EMIL BEHNKE, 18 EarFs Court Square, London.

“ Pre-eminent success in the education and treatment of stammering and other speech defects.”
^The Times.

“ Mrs. Emil Bebnke is a recognised authority on vocal training.” — The Queen.

“ I have confidence in advising speech sufferers to place themselves under the instruction of
Mrs. Behnke.” — Editor, Medical Times.

‘‘ Mrs. Behnke is well known as a most excellent teacher upon thoroughly philosophical
principles.” — Lancet.

“ Mrs. Behnke was chosen from high recommendations, and very thoroughly has she proved
worthy of them." — Letter by Dr. Nicholls on Stuttering, British Medical Journal.

“ Mrs. Behnke has recently treated with success some difficult cases of stammering at Guy’s.”
--Gtty's Hospital Gazette.

Mrs. liehnke’s work is of the most scientific description.”— .d/fc’f/fVrt/ Magazine,

« STAMMERING 8 CLEFT-PALATE SPEECH, LISPING.” Is. net, postage l^d.

STAMMERING and Defects of Speech.

Pro-F. J. HERBERT MIALL’S simplifiecl method, recommended by Dr. A. W.

Upcott, of Christ’s Hospital School ; Dr. W. T. Barber, of The Leys School, Cambridge *, Dr.
C. R. L. McDowall, of King’s School, Canterbury ; F. S. Young, Esq., M.A., of The College,
Bishop’s Stortford ; and Horace Puckle, Esq., M.A., of Uppingham. Success is obtained by
periodical visits without the loss of School Term or Business Time.

Address: 6 ARGYLL PLACE, REGENT STREET, LONDON.

PRIVATE SCHOOL FOR THE DEAF.

Spring mu, NORTEUIMPTON.

(Charmingly situated m its own grounds facing the open country.)

Principal : F. INCH JONES, B.Sc. (Loud.)

Member of the College of Teachers of the Deaf.

Deaf Boys, Sons of Gentlemen, given a thorough education by the Oral System of Speech and
LipTeading. Unique Exam. succes.ses. Cricket and Football with hearing boys.

Prospectus on application.

LONDON SCHOOL OF MASSAGE AND

126 May-fair

MECHANO-THERAPEUTICS.

C OURSE lasts from three Months. Pupils can join at any time. Daily
supervision. External Candidates examined. Certificates granted. Other
Courses can be arranged. Reduced fees for Nurses and special facilities.

For Prospectus apply to Secretary :

211 GREAT PORTLAND STREET, LONDON, W.

ADVERTISEMENTS

857

EPILEPSY. THE DAVID LEWIS GOIOHY,

Solely for the benefit ’of Sane Epileptics ; stands in ite own grounds of nearly rSo acres, and is
situated in a beautiful part of Cheshire, two and a half miles from Alderley Edge Station, and
fourteen miles from Silanchester. Electric light throughout. Perfect Sanitation. The Colony
system ensures for Epileptics the social life and employment best suited to their needs.

TERMS. FOR MIDDLE AND UPPER CLASS PATIENTS FROM 30s. A WEEK
UPWARDS, according to accommodation and requirements.

For -further infornnation apply to the Director, Dr. IVIcDOUGAI.L,
Warford, near Alderley Edg^e, Cheshire.

School 5or Epileptic Boys.

COLTHURST HOUSE, WARFORD, ALDERLEY EDGE.
Under the Management of the Committee
of the David Lewis Colony,

Home life, Medical care, and suitable education for boys subject to
Epilepsy. Terms 30s. weekly.

Purther particulars maybe obtained from Dr. A. McDOUGALL,THk COLONY, ALDERLEY EDGE

<El{>ilet>sg & iVIental jDeficicncg.

NEW LODGE, BILLERICAY, ESSEX.

For 50 Gentlemen, not under certificate of Insanity, suffering from Mental or
Nervous Diseases. Separate Bungalow for Epileptics. Medical Officer, H. J.
PRICE, F.R.C.S. Eng. Inclusive Terms, One Guinea Weekly.

Secretary, CO-OPERATIVE SANATORIA Ltd. Billericay, Essex.

gT. LUKE’S HOME ==—
for Epileptic Churchwomen.

WORKING CASES - - 15s. WEEKLY.

DEACONESS, St. LUKE’S, SWANMORE, RYDE, I. of W.
SURREY MIL-US.

THE BEECHES, WRAY LANE, REIGATE HILL.

Home for NERVE PATIENTS, REST CURES, MASSAGE, ELECTRICITY, DIET,

Perfect Situation, facing South. Elevation COO ft. Glorious views. Pretty
grounds.

PATRONIZED BY MANY LEADING SPECIALISTS,

Apply MISS GOSLETT. Telephone: S28 RedhilL

St. ANDREW’S HOSPITAL

DolUs-Ull, LONDON, N.W.

A HOSPITAL FOR PAYING PATIENTS OF LIMITED MEANS.

Medical and Surgical, but not Mental or Contagious cases. General
Wards and Private Rooms. Resident and Visiting Medical Staff ; Trained
and Certificated Nurses.

Telephone : WILLESDEN 898. ^ Apply - THE- MATRON.

858

ADVERTISEMENTS

Telephone : 2253 Mayfair. Telegrams : “ Nursingdom, London.”

CO^FEBATION OF TEMPERANCE

MALE & FEMALE NURSES

58 WEYMOUTH STREET,
PORTLAND PLACE, LONDON, W.

Reliable and experienced Nurses for all cases at all hours.
A special staff of experienced and tactful Nurses for .Mental,
“ Borderline,” Neurasthenia, Nerve and Rest Cure Cases,
Skilled Masseurs and Masseuses to work ‘ under Medical
Supervision,

Apply M. SULLIVAN, Secretary : or Lady Superintendent.

NAKCHESTKR AND I^BKDS.

MRS- HARWOOD, Member of the Incorporated Society of Trained
Masseuses^ Dist. Cert.

TEACHER OE MASSAGE, PHTSIOJaOGY, ANATOMY,
BANDAGING, SWEDISH EXERCISES & EDECTRICITY.

Students prepared for the Incorporated Society’s Examination, and are recoin meudecl to sit
for the same. The course for Massage includes, Anatomy, Physiology, Practical Massage and
Theory of Massage, according to the requirements of Society. Doctor’s lectures. GUuique,

Apply— 102, NICOLAS ROAD, CHORLTON-CUM>HARDY, MANCHESTER.

6ih Edition. Revised and Enlarged. Many Illustrations. 7/6 net.

LECTURES ON

MASSAGE AND ELECTRICITY

IN THE TREATMENT OF DISEASE.

By THOMAS STRBTCH BOWSB, M.D. Abd., F.R.C.P. Bd.

“ The book is to be commended, and will be found an accurate and complete guide on the
subject of massage.”— Lawcfii.

'jth Edition. Reprint. 2/--. Numerous Illustrations.

MASSAGE PRIMER (FOR LEARNERS)

By THOMAS STRETCH BOWSE, M.B.

The text is clear, the illustrations are excellent. If any book can teach the art, surely
this one should succeed.”— Medico- Chirurgieal Journal.

“Beginners in the study of massage will find in this little book much that will instruct them,
and those who have long since begun will be interested if they are still, as they should bo,
‘ learners.’ ^'—Medical Revieiv.

BRISTOL: JOHN WRIGHT SONS LTD.

ADVERTISEMENTS

&59

.Teleplioiie: 2437 PADDINGTON.

Telegrams: “ASSISTIAMO, LONDON.”

Male N urscs’
Association

29 York St., Baker St., W.

ESTABLISHED 15 YEARS.

Careful and reliable Male Nurses sent out,
at moderate fees, for all cases, day or night.
Masseurs supplied by the hour or week.

W. GUTTERIDGE, SuperiniendenU
W. J. HICKS, Secretary,

THE LONDON TEMPERANCE

MALE AND FEMALE NURSES

oo-oPx:z2..^TioiNr

Telephone 2302 Mayfair. 18, ADAM STREET,

' NursJontem,” Baker, ^ PORTMAN SQUARE, W.

London, * *

TJ'OR supplying the Medical Profession with Superior Trained and Certificated
Nurses for Medical, Surgical, Mental, Dipsomania, Maternity, Fever and
Travelling Cases at a moment’s notice — Day or Night.

The Nurses are Fully Insured against Accident.

Nurses receive their own Fees.

Terms from £1 16s. 6d. to £3 3s. per week.

Please address all Communications to C. WEBB, Secretary.

MENTAL NURSES’ CO-OPERATION

For the Supply of CERTIFICATED MENTAL NURSES,
49, NORFOLK SQUARE, LONDON, W.

The Co-operation, which has the approval and support of many Mental
Specialists, was established in 1907. All Nurses sent out are insured against
accidents. Apply to the Lady Superintendent, Miss Jean Hastie.

Telegraphic Address : Nurseiital, Paddington. ^ RESIDENTI/ULf HOME

Telephone : No. 6533 Paddington.

FOR NURSES.

86o

ADVERTISEMENTS

St LUKE’S HOSPITAL,

Old Street, LONDON.

TRAINED NURSES

FOR MENT.A.L- Si. NERVOUS CASES.

OAN BE HAD IMMEDIATELY.

APPLY MATRON.

Telegrams: ENVOY, FINSQUARE, LONDON. Telephone: 5608 Central.

A HOME FOR INVALID AND AGED LADIES

Requiring Nursing and Medical Attendance.

QUEENSBERRY LODGE, HOLYROOD

SDIN-BXJRG-XX.

ORDINARY DIRECTORS— Lewis Bii.ton. Esi'i., W.S. (Chairman)-, The Rialit Hoiiomable the
Loro Provost ,* The Sheriff ; The Dean of Guild ; Wai, Tho.msojV, Jilsq. ; A. W. Robert-
son-Durham, Esq,, C.A, ; Rev. Thoma.s White; John Kerr, Esq., LL.l). ; W. Okmiston,
Esq., J.P*; Sir James A. Russell, M.D, ; Councillors Barrie, Bathgate, and Robertson;
Rev. P. W. Paterson, D.D, ; J. Stuart Gowans, Ksq., C.A.

Cons^tUing Physician —

Visiting Physician — William Russell, M.D., F.R.C.P.K,

Governor and Treasurer — A. ^Iiller, Esq, Afatron — Miss Riddei.l,

Rates of Board from £50 to £100 per annum.

Particulars may be obtained front the Govf.rnok, Queensberry Lodgic, Edinburgh.

Medical Establishment, Paris.

THE MOST COMPLETE IN TRIE WORLD,

Electricity, Water, Heat, Movement, Zander’s Method, Roentgen Rays, Radium, etc., etc.

25, RUE DES MATHURINS, 25, OPERA.

BNQUSH CONSULTINQ PHYSICIAN seen at any time.

Residential Home for Patients : 15, BOULEVARD MADELEIHE, PARIS.

ROYAL DEVON and EXETER HOSPITAL

PRIVATE NURSING BRANCH

Trained Medical, Surgical, Fever and Massage Nurses supplied. For terms
apply “The Matron,” Royal Devon and Exeter Hospital, Exeter.
Telegrams— “ Nursing, Exeter.” Telephone— No. 45.

ADVERTISEMENTS

86l

Church Stretton Nursing Home

FOR MEDICAL, SURGICAL. AND
a CONVALESCENT PATIENTS.

The Misses NICHOLLS & SILVERLOCK, Ashford House, Church Strettou.

“ NORMANSFIELD.”

A Private Establishment for the care and training of the

MENTALLY DEFICIENT.

Patients of either sex, including quite young children, received.
Separate houses for the slighter grades of defect.

For particulars apply to the Resident Physician and Proprietor, Hampton Wick.

NEURASTHENIA and Allied Disorders.

PREBEND HOUSE, SOUTH WELL, NOHS.

T IMITED NUMBER OF PATIENTS RECEIVED by medical man in his private
" residence for Weir-Mitchell Treatment, Rest Cure, Massage, etc. Complete Electric Insiaila.
tion, including X*Ray, High Frequency, Galvanic, Faradic, and Sinusoidal Currents ; Ionisation,
Schnee’s 4-cell Bath, etc, Bergonie's Apparatus for treatment of Obesity, Heart Disease, Neuras-
thenia, etc. No Mental, Epileptic or Tubercular Cases taken,

Apply to T. S. ELLIOT, L.R.aP., M.R.C.S., 0 .P.H.

= Prloate Borne for Inoallds. =

HORFIELD OOMMON,"”

Mrs. GOTCH, TRAINED LADY NURSE, takes Patients.

Doctor’s Reference. Every Care and Attention given.

MOORCOTE SANATORIUM

(Est. 1899 ) for the Treatment of Tuberculosis.

Situated amid pine.s, 36 miles frotn London. Pure air, mild sunny climate, gravel subsoil, e.\tejisive
and very slicltered grounds. P,edr<jums and chalets with balconies. Home-like and comfortable.
Excellent Food. Spengler’s I.K., Tuberculins tested in F.hrlich’s Laborator3’, and Inhalations used.

Terras from 2>2 Guineas. Physician : Dr, J. G. GARSON.

Matron and Trained Nurses. Vacancies in Ladies’ and in Gentlemen’s Departments.

Apply to the SECRETARY, EVERSLEY, HANTS,

JOHN WRIGHT 81 SONS Ltd. BRISTOL,

For CHARTS and CHART HOLDERS.

Catalogues
Free on
application

862

ADVERTISEMENTS

f ansdown ^ roue R ouse,

B>5s.TM.

430 feet above sea.
Electric Ligrhting.

A Public Institution
founded under the
Jennings’ Trust, and
specially adapted for
Rheumatic and
Arthritic Patients,
requiring

SKILLED

NURSING,

BATHS,

AND

PHYSICAL

TREATMENT.

ARRANGEMENTS FOR ALL CLASSES.

Full Particulars on Application to Lady superintendent.

SOUTH BEACON,

HADLOW DOWN, BOXTED, SUSSEX.

ESTABLISHED 1892.

For GENTLEMEN SUFFERING FROM

NERVOUS or SLIGHT ME NTAL BREAKDOWN.

■pORTY Acres. Poultry Farming. Riding, Motor, Billiards, Golf, etc.
A Special attention given to Patients suffering from Insomnia of
Neurasthenia, or overwork and worry. Terms from £S 3s. Weekly.

Apply to - PHILIP H. HARMER.

ROSEVALE HOMES for PAYING PATIENTS.

PENNS LANE, ERDINGTON, near Sutton Coldfield.

(Under the distinguished patronage of The COUKTESS OP BSADFORD.)

Receives any but Mental or Infectious Patients. ,

Rest-Cure Treatment and long-standing Surgical Dressings a Speciality.

(Residential Masseuse in attendance.)

Grounds extend to, and overlook, Walmley Golf Links,

Detached HOMES for PERMANENT PATIENTS. CARE of ONE DELICATE CHILD.

Illustrated Booklet on application to Miss C. L. FALLOWS (Matron).
Telejihcne: iij Erdhi^Ufi. Telegrams : Nursing^ ErdtngiotiT

ADVERTISEMENTS

863

Manna Mead Home

FOR INVALroS. — ESTABLISHED in 1893,

IS situated in a cosy corner on the top of Blackheath Hill, London,
facing South, and overlooking the Heath, and surrounded by fine
trees. At the back of the house there is a garden, where Convalescents
may sit or lie in hammocks under the trees, imagining themselves miles
away from London, instead of fifteen minutes* walk from Lewisham
Junction* The arrangements throughout are most comfortable, and
suggest a private house rather than an Institution.

Rest-Cure and Weir-Mitchell Patients, Paralysis, Neurasthenia, Neuritis
and Rheumatoid Arthritis, Etc.

TERMS - from £3 3 0 per week. | Permanent Patients - from £2 2 0

The little cottage standing at the bottom of the garden is of great interest,
for in it invalid, aged and bed-ridden ladies are received at very reduced fees.

Any desiring further information should apply to the Principals —

Mrs. KNIGHT and Miss TAPLEY SPURR,

MANNA MEAD, 17, THE GROVE, BLACKHEATH, LONDON, S.E

Telephone: 976 Lee Green.

The dietary is carried out under the personal direction of Mrs. Knight, who
has been specially trained in Cookery. Miss Spurr is a certificated Hospital
Nurse and Masseuse. The outfit of the house, containing all the modern appli-
ances, meets all possible requirements.

—HOME FOR INVALIDS

The Laburnums^ Heronsgate^ near Chorleyzoood, Herts.

Private Home for all kinds of Nervous Cases of the Middle Class. Stands in its own
grounds of several acres, at an altitude of 500 feet above sea level. Air very bracing.

Soil— gravel on chalk. Gardening and Out-door Amusements.

Epileptic and Paralytic Cases not objected to. Highly recommended by the Medical
Profession. — Established 1880. — For Terms, apply to the Proprietress, Mins KING.

864

ADVERTISEMENTS

$. Thomas’s Home,

S. THOMAS’S HOSPITAL,

WESTMINSTER BRIDGE, S.E.

FOR PAriN O PATI E NTS,

The Resident Medical Officer can be seen daily at 12 noon.

Full particulars may be obtained on application to

Telephone ; Hop 1637. SIDNEY PHILLIPS, B.A., Steward.

A limited number of Poor Paying Patients are admitted into the General
Wards of the Hospital upon payment of three shillings per day.

LYNWOOD,

MOUSEHOLE,

CORNWALL

Sheltered Situation on
High Ground over*
looking Mount’s Bay,

No mental
or infectious
cases.

Terms from

* £3 3s. Od.

Miss Enid Smith. M.B.. B.S, (Lond.), receives Women and Children in need of rest
and changre or medical Treatment.

WINTER TEMPERATURE HIGHEST IN ENGLAND.
SUNSHINE RECORD 1825 HOURS PER ANNUM.

Convalescent Mome ™ bmghton
for AV^omen and Children.

Hon. Secretary and Treasurer ; PRANK HOLT, 8, Cook Street, Liyerpool.

Hon. Consulting Physician: WILLIAM BELL, M.R.C.S. (Eng.), L.S.A. (Lond.).
Honorary Medical Officers :

A. W. RIDDELL, M.R.C.S. (Eng.), L.R.C.P. (Lond.); E. AUGUSTINE BELL, M.B., B.S.(Lond.)*,
CHAS. WILSON, M.B. & C.A. (Glas.); SEYMOUR W. DAVIES, M.B., Ch.B. (Yict.).
Hon. Dental Surgeon: ARTHUR CAPPER, L.D.S.. R.G.S. (Edin.).

Lady Superintendent: Miss K. R. BOLTON.

T he Home is open all the year round for the receptioti of patients recovering fronr illness, or
requiring vest and change at the se.aside.

During the winter months the whole building is well warmed by an efficient heating apparatus,
and thus the Home is made a pleasant residence for delicate persons even in the most severe
weather, and a beneficial resort in the winter as w’ell as in the summer.

The house is built on the shore, by the new Promenade, and within a few minutes’ walk of the
Landing Stage and Railway Station.

There is a special department for Gentlewometi. Each Lady has a separate bedroom.

An Attnual Subscription of One Guinea entides the subscriber to nominate at reduced rales
either one 3 ?atient for four weeks, or two Patients for two weeks each.

TERMS : First Class, 15/«, and Second, 6/0, with Nominations. Unnominated, 6/~ k 4/- extra*

AD VERTISEMEN TS

865

Invalid, Medical and
■ Surgical Home -

For well-conducted, refined CHILDREN.

Received for Rest and Open-air Treatment.

No case received recovering from anything infectious,
nor pulmonary consumption.

A COMPETENT STAFF OF NURSES AND RESIDENT GOVERNESS.

Apply : —

UDY SUPERINTENDENT, BISHOPSBOURNE, BROADSTAIRS.

Telegrams : Blshopsbotirne, Broadstairs. Telephone : No. 75 Broadstairs.

St LEONARDS-ON-SEA, 57 Marina

Nursing Home for Medical, Surgical,
Weir- Mitchell, and Chronic Patients.

RADIANT HEAT AND LIGHT BATHS.

For Terms apply to Miss South.

Telegrams: “Womanly.” Telephone: 42 Hastings,

== BOURNEMOUTH. =

HOMES m PAYING PATIENTS

AND INSTITUTE FOR TRAINED NURSES.

Twenty-four Beds from 3J to 5 Guineas, also Eight Beds (Two Beds in
a room), at 42/- per Week.

FULIY TRAINED NURSES supplied for Medical, Surgical, Maternity, Massage,
Electricity, Fever and Mental Cases, from 35/6 to 4 Guineas per Week.

Apply to The Matron, Cambridge Road.

Telegraphic Address: “ Nightingale, Bournemouth." Telephone No. 102

S66 advertiskments

Abbey Green, Jedburgh.

Established I87t. Enlarged 1894.

Dr. Blair receives into his House a limited number of Patients
requiring Care and Treatment. Motor-Car Exercise.

Dry Climatei ^ Beautiful District. Terms Moderate.

Telephone No. 3.

PRIVATE NURSING ASSOCIATION, LTD.

Warnsfonl Hoiu., ROYAL LEAMINGTON SPA.

Patron : The Right Hon. Lord Leigh.

Refined Home for Children (boys or girls) with every care and attention.
Moderate Fees, Infants received from Birth or otherwise.

For Terms apply: MRS. JAMES WARD, M.LH.

TEIGN MOUTH. DEVON.

Pleasantly situated Home for Patients, Convalescent and
Delicate People, Maternity Cases, or Children.

Sister, BttelceridLs^e Lodig^e.

TELEPHONE : TEIQNMOUTH 52

IHounc €pl)raim Rursing Dome,

8, Molyneu x Par k, TUNBRIDGE WELLS.

Medical, Surgical, Weir Mitchell, and Massage Cases received. Dowsing.
Radiant Light, Heat Baths, &c. Excellent facilities for Open Air Treatment.
Under the personal supervision of Miss Baxter (Late Superintendent
County Cork Hospital.)

Telegraphic Address ; “Leo.” Telephone: No. Cl 5.

COM PORTABLE HOME FOR LADIES.

ST. URSULA, ■yjSSWESTCLIFF-ON-SEA

HOUSE is detached, with an extensive sea view ; on high ground, with good garden,
and bright sunny rooms. The air and water are considered exceptionally good.
Patients Receive every Comfort and Attention. Trained Nwrsi^s are KEri’.

All needing rest, care or supervision. Chronic Invalids and the Aged gp^daUy, cared for.

Fxill Particulars and RefeT'enccs gh'en on applkaiion to SIISS HASLOOiE. j
Terms according to requirements. Telephone: 84 LelSh<ohwfi^

ASSOCIATION OF MEDICAL MEN RECEIVING

RESIDENT PATIENTS.

Any INVALID wishing to reside with a Medical
Man, at home or abroad, should apply to Hon. Sec.
27, WELBECK STREET, W.

SOUTH AMERICA

SOUTHAMPTON, |
LIVERPOOL AND
GLASGOW,

Via FRANCE, SPAIN,
PORTUGAL, MADEIRA,
CANARY ISLANDS,.

ST. VINCENT,

FALKLAND ISLANDS.

FORTNIGHTLY TO

WEST INDIES, PANAMA CANAL,

PACIFIC PORTS, NEW YORK (For BERMUDA).

CRUISES TO NORWAY,

MEDITERRANEAN, HOLY LAND, EGYPT, WEST. INDIES, S:c,
By Ocean Yachting: Steamer “ARCADIAN.”

JUNE TO DECEMBER, From £1 A DAY.

FORTNIGHTLY TOURS TO

MOROCCO MADEIRA,

23 DAYS - £18.

LONDON : 18 MOORCATE ST., E.G., and 32 GOGKSPUR ST., S.W.
LIVEHPOOL; 31 JAMES STREET.

Favoiirite Situation over the Promenade

200 Rooms with balcony, offering
splendid view on Skating Rink and
Surroundings. Facing the South,
Own park and woodlands. The
most famous Physicians visiting the
Hotel.

Write for Prospectus.

Director.

Ch. ELSENER.

ADVERTISEMENTS

869

MEDICAL DIETETICAL INSTITUTION

VAL-MONT, TERRITET

(SWITZERLAND.)

Altitude 2,200 feet. Open all the Year.

Director; DR. WIDMER. ' THREE ASSISTANT DOCTORS.

Diseases Specially Treated at Val«Mont :

1. — Diabetes, Obesity, Anaemia, Chlorosis, Gout, ILoss of Flesh,
General Weakness, and other troubles affected by Diet.

3. — Diseases of the Digestive Organs, the Stomach, the
Intestines, the Liver, and Nervous Dyspepsia.

3. — Disorders of the Heart and Circulation. (Terrain Cure,

Carbonic Acid Baths).

4. — Chronic Diseases of the Kidneys, Albuminuria.

5. — Fatigue resulting from Overwork, and Convalescence after Operations

or Acute Diseases.

Hydropathy. Electropathy. Electric Baths. Radiopathy,
Radiography. Swedish Massage and Gymnastics, etc.

Tubercular diseases of the chest or contagious diseases are strictly e.xcluded,
as well as all patients who are very nervous, agitated, morbid, hypochondriac,
or physically affected.

BELLEVUE SANATORIUM,

KREUZLINGEN.

Dr. BINGSWANGER’S SANATORIUM, Established 1857.

Medical Superintendent - - Dr. LOUIS BiNGSWANGER.

Resident Physicians - Drs. HAYMANN, REESE, and SCHON.

Manager - OTTO BiNGSWANGER, Ph.D.

Sanatorium for the combined Treatment of NERVOUS and MENTAL
DISEASES. Detached Villa system, by means of which patients suffer-
ing from different diseases can be kept entirely separate. Seven Villas
for Neuroses, conditions of Nervous Prostration, Minor Psychoses, and
Convalescence. Three Villas for Mental cases. Complete installation
for Hydro- therapy. Gymnastics, massage, sea-water baths, gardening,
weaving, etc. Home life.

Price of Pension, including Medical treatment, heating and light,
and exclusive of personal laundry and drugs - per day, 1 5 fcs.

Room, from 3 fcs. Special Nurse, if necessary 7.50 fcs.

Special arrangements for One or more Private Rooms.

Address

KREUZLINGEN. CANTON THURGAU, SWITZERLAND.

ADVERTISEMENTS

Ripen $p9 'S"

AS A HEALTH RESORT.

Delightfully situated it\ the tn'idst of the C/^RDEH OF YORKSHIRE;’

The New Spa and Baths,

with an unfailing supply of Sulphur Water for the treatment
of Gout, Rheumatism, Skin Diseases, etc.

Also Pine, Droitwich Brine and Nauheim Baths. Intestinal
Douche (Plombieres method).

Also equipped with one of the latest and best Electro-
Therapeutic Departments, including X“Rays, High Frequency,
Ionisation, Vibratory Massage, Schnee Four-Cell Bath, Electric
Immersion Baths.

The whole of the Departments are now under the control
of a Manager and Matron with considerable experience in all
kinds of Hydropathic Treatments, and the Medical Profession
can be assured of the best attention and treatment being given
to their Patients.

VISITORS AND INTENDING RESIDENTS are invited to apply to the

TOWN CLERK for ILLUSTRATED BOOKLET (Gratis.)

G.N.R. QUICKEST ROUTE

LONDON (King’s Cross) & RIPON.

Principal Express Trains Week'days. Suns.

King’s Cross dep, |

Ripon ... arr.

R 1
a.m.

7 15 ]
2 36

a,m.

10 10
3 45

a.m.
10 35
4 47

p.m.

1 40

1 6 25

p.m.
2 20

1 8 8

p.m.
4 0
9 2

S o
p.m.

5 45
11 31

noon
12 0
6 0

Ripon ... dep.

King’s Cross arr.

a.m.
7 36
1 5

a.m.
8 11
1 55

a.m.
9 40i
2 15

a.m.
ill 44

1 5 25

p.m.
12 13
6 15

p.m.

1 46
7 0

p.m.

3 54
9 25

p.m,
5 32
10 45

a.m.

9 49
5 45

T— Through Express. R — Restaurant Cars. S O— Sats. Only.

For full particulars of train service, fares, etc*, apply to Supt. of the Line, G.N.R.i
King's Cross Station, London, N, or at any G.N. Office.

ADVERTISKMENTS

871

PCCDI EC

HOTEL HYDROPATHIC.

A PALATIAL MODEBA KIIR HOTEL

=== IN SCOXI.AND ======

Situated amidst the most charming scenery in Peebleshire.
700 feet above sea level. A complete equipment of all Modern Baths.

P?orio*n ni (Volcanic Mud Packs for Gout, Rheumatism,

* Lumbago, Sciatica, etc. Radium Emanations )

NAUHEIM BATHS and SCHOTT EXERCISES. WEIR-MITCHELL TREATMENT.
TURKISH BATHS; RUSSIAN BATHS. VICHY and AIX-LES-BAINS DOUCHES.
ELECTRIC LIGHT BATHS. PLOMBlERES TREATIWENT.

DOWSING RADIANT HEAT. DIATHERMY.

AACHEN AND FRENKEL SYSTEM FOR LOCOMOTOR ATAXY.

RADIUM EMANATIONS. BEROONIE TREATMENT OF OBESITY.
DROITWICH BRINE BATHS; SULPHUR BATHS; ' PINE BATHS.

SINUSOIDAL, HIGH-FREQUENCY AND X-RAY TREATMENT.

FOUR’CELL ELECTRIC BATH; INHALATIONS. STATIC ELECTRICITY.

ELECTRIC VIBRATION. SPECIAL DIETING.

EXPERT MASSEUR; MASSEUSSE; NURSING SISTER,

Every comfort for INVALIDS and the CONVALESCENT.
Sheltered Balconies, Wind Screens, and Open-Air Chalets.

Medical Superintendent: THOMAS D. LUKE, M.D., F.R.C.5.

(Formerly of Matlock).

GOLF.— Excellent 18-hole Course within 16 minutes’ walk.

Croquet, Tennis, and Bowling Greens. Motor Garage.

: : Every Form of Indoor and Outdoor amusement. : :

For Terms and Prospectus apply —

W. A. THIEM, Manager, PEEBLES, N.B.

S72

ADVERTISEMENTS

ROCKSIDE HYDRO.,

MATLOCK.

HIGH-CLASS HEALTH AND PLEASURE RESORT
FOR WINTER AND SUMMER.

EARLY 800 feet above Sea Level. Dry, Bracing, and Health-giving. Complete
in own Extensive grounds commanding charming views. Well-sheltered.

CROQUET (TWO LAWNS). TENNIS (Dry AND GRASS COURTS),

BOWLING AND PUTTING GREENS. BILLIARDS.

Near the GOLF LINKS (18 Holes). GARAGE.
GRAND LOUNGE AND BALLROOM.

EVENING ENTERTAINMENTS all the Year round.

ELECTRIC LIGHT AND LIFT. TABLE' D’HOTE, 7 P.M.

SPECIAL NOTICE:

The New Baths include Turkish, Plunge, Russian, Aix
AND Vichy Douches, Electric Light and Heat Baths, High
Frequency, Schnee Four-Cell, X-Rays, and the Latest Electrical
Appliances. The Ladies, and Gentlemen’s Baths are respectively under
the supervision of a Resident Lady Physician and a Visiting Physician.
A thoroughly efficient Staff, including Trained Nurses. Night Attendants.

Incittsive Terms : 2i to 3i GUINEAS WEEKLY.

(Reduction for Winter Residence.)

Miss Goodwin
Mr. John G. Goodwin

fMaticrgcrs.

Write for Illusfraied Prospectus.

AD VE RTISE ME NTS

873

SMEDLEY’S

Hydropathic Establishment,

MATLOCK.

ESTABLISHED 1853.

Pbs5ic<an9 :|

G. C. R. HARBINSON,' M.B., B.Ch., B.A.O. (R.U.I.)-
R. MacLELLAND; M.D., C.M. (Edin.), resident.

A COMPLETE SUITE OF BATHS, including separate Turkish
and Russian Baths for Ladies and for Gentlemen, Aix Douches, Vichy
Douche, and an Electric Installation for Baths and ]\Iedical purposes,

DOWSING RADIANT HEAT

D'ARSONVAL HIGH FREQUENCY
RONTGEN X-RAYS NAUHEIM BATHS

FANGO MUD TREATMENT.

Special provision for Invalids. Milk from own Farm. American
Elevator, Electric Light. Night Attendance. Rooms well ventilated, and
all Bedrooms warmed in Winter throughout the Establishment. Large
Winter Garden. Extensive Pleasure Grounds. Matlock Golf Links, iS
holes, within 15 minutes’ walk, regular Motor Service.

MASSAGE & WEIR-MITGHELL METHODS OF TREATMENT.

A Large Staff {upwards of 60) of Trained Male and Female Nurses, Masseurs

and Attendants.

Terms : 3 to 4 Guineas per Week inclusive, according to Bedroom.

(WINTER REDUCTION.)

Prospectus and full information on application to

H. CH ALLAN D, Managing Director.

Telegrams : Smedley’s, IMati^ck Bank.’* Telephone No, 17.

ADVERTISEMENTS

Strathpeffer Spa.

The BEN WYVIS,

THE PBINCIPAL HOTEL AT THE SPA.

F inest situation, with private walk to the Wells and Baths, and to the
Pavilion and Spa Gardens, in which a splendid Orchestra plays daily.
Stan3s in its own Grounds, amidst magnificent Scenery, in full view of Ben
Wyvis and the policies of Castle Leod,

Spacious Lounge and Reading Room, Music, Billiard and Smoking
Rooms. Perfect Sanitary arrangements. Electric Light. Passenger Lift to
all Floors.

ILLUSTRATED TARIFF FREE ON APPLICATION.

Bowling) Tennis, & Croquet Grounds ; near excellent Golf Course, 18 holes.
An attractive Practising Course within the Hotel Grounds.
Spacious Motor Garage with Inspection Pits and all accessories.

HE.m Qu.\»ters of the Royal .4Nd ^ SUPERIOR SALMON and

Scottish Automobile Clubs ... ^ TROUT FISHING.

Telegrams; BEN-WYVIS HOTEL. STRATHPEFFER.

ADVERTISEXIENTS

III

BUXTON. (PEAK of DERBYSHIRE)

TME JVlOUNTA.IISr SF^^.

WATERS. — Thermal (82° F.), strongly Radio Active- Tasteless and Odorless.
Chalybeate Springs.

TREATMENTS. — Bathing Establishment most comfortable and complete in Great
Britain. Over 80 Treatments. All forms of Massage. Buxton, Aix, Vichy*
etc. Vapor* Sprays, Douches* Immersion* Swimming, Plombieres treatment
(Waters almost identical with Plombieres), Moor, Fango and Peat Baths and
Packs (see Dr. Guy Hinsdale’s “ HYDRO -THERAPY,” re Buxton Packs).
Electrical Department, every Treatment. Nauheim, Schwalbach, Chalybeate,
Oxygen and Medicated Baths, etc.

INDICATIONS. — Rheumatic and Gouty conditions, Neurasthenia, Sciatica,
Rheumatoid Arthritis, Chronic Myalgia and Arthritis, Neuralgias, Neuritis,
Locomotor Ataxy, Skin Diseases, .Anemia, Heart Trouble, Tropical Diseases,
Mu:o Membranous Colitis, Catarrhs of the Respiratory Tract, etc., etc.

EXCURSIONS AND AMUSEMENTS.— The most beautiful scenery in the
country surrounds Buxton, and unrivalled facilities for comfortable and cheap
excursions are provided. First-class Orchestral Band, Opera House, Variety
Theatre, Tennis, Croquet, Bowls, Golf, Angling, etc., etc.

CLIMATIC. — The most bracing, dry, and pure air in the country. Elevation
1,000/1,250 feet.

Members of the profession are cordially invited to test for themselves the numerous

advantages Buxton offers as a Spa and Health and Pleasure Resort.

Free Guide and further details from BATHS MANAGER, BUXTON,

UNRIVALLED as a WINTER RESORT.

IMPERIAL HOTEL

'■■■ ^ G" ' ~~

UNDEF ENTIRELY NEW MANAGEMENT.

Principal Hotel, standing in Private Grounds of 7 acres.

FACING THE SEA, Every Comfort. Moderate Charges.

GOLF - TENNIS - CROQUET.

ELECTRIC LIFT. GARAGE.

Fresh-water Fishing Free to Visitors.

For Tariff apply to - - - E. SCHULT.

ADVERTISEMENTS

H76

PROITWICH,

ENGUND’S brine baths spa

WoHd-renownedj for
Treatment of Rheumatism,
Gouty Sciatica, Rheumatoid
Arthritis, Neuralgria, Neuritis,
Lumbagro, Paralysis, etc.

Reclining, Deep Bath, Douche, Aix
Douche, Needle & Magnificent Swim-
ming Baths, all supplied direct from

THE NATURAL
BRINE SPRINGS.

Also the Nauheim treatment

VISITED BY THOUSANDS ANNUALLY.

TREATMENT IN THE NATURAL BRINE can only be obtained at DBOITWICH, and the
NATURAL BRINE HOLDS IN SOLUTION SALTS EQUALLING
“ ABOUT 100 lbs. TO AN ORDINARY RECLINING BATH. -
RECOMMENDED A 2I hours direct route by Great Western Railway from London ; also

AT Al L ^ served by Midland Railway. Convenient from all districts. Picturesque

c ni c Country. Excellent Roads, Capital centre for Worcester, Stratforci-ou-Avon,

SEASOfIS. Broadway, Tewkesbury, Warwick, and numerous other places of interest.

GOOD HOTELS. BEAUTIFULLY LAID-OUT PARK. DAILY MUSIC.
GOLF. BOATING. FISHING. CAPITAL H UNTING.

Further particulars and Illustrated Booklet free, from : —

J. H. HOLLYEB, (Manager of Baths, &c.). 24, Corbett Estate Offices, DROlTWlCH.

THE

W or«sKr$l)lre B rine B atbs h otel

(Adjacent to the MODERN ST. ANDREW’S BRINE BATHS.)

WINTER HEALTH RESORT. DROITWICH.

150 ROOMS.

Several Suites, and many
South Rooms, also Bed-
rooms on Gi^ound Floor.

ONLY HOTEL WITH LIFT.
NEW SMOKING LOUNGE.

LIBRARY
BILLIARDS
NIGHT PORTER.

Beautiful Drives,
Walks and Excursions,

GOLF LINKS, TENNIS,
CROQUET,

GARAGE FOR MOTORS
with Lock-ups.

TABLE D’HOTE DINNER AT SEPARATE TABLES, 7 p.m.

MODERATE INCLUSIVE TERMS. SPECIAL ADVANTAGES TO MEDICAL MEN IN PRACTICE.

Telegrams — “ Wo7'cesfers7ti7-e Hotels Droitwich* TeleJ>7wne^ ATa. 2 Ojjfice.

Write for 1lmjste:.\ted Prospectus. „ ,, 48 Fisitnrs.

R. P. GULLEY & CO., Ltd., Proprietors. — T, K. GULLEY, Manager.

ADVERTISEMENTS

877

HOT SPRINGS

BATH

RICH IN NATURAL RADIUM EMANATION

Used with great success in Gout and Rheumatism
in all forms, Sciatica, Muco- membranous Colitis, Tropical
Diseases, various Diseases of Women, etc.

Sport and Amusements of all kinds for the entertain-
ment of Cure-guests. Season: All the Year round.

** Notes on the Therapeutics of Radium in the Bath Waters,’*
Illustrated Hand-book to Bath and all information free to Medical
Profession from John Hatton, Director of the Baths, Bath.

THE HYDRO, college green, Bristol

BATHS comprise : Turkish, Eiectric, Radiant Heat & Light, Nascent-Sulphur, Brine, etc.
Ionic Medication, Diathermy (for circulatory disturbance, sciatica, etc.)

High Frequency, Leucodescent ” Lamp (for Fibrositis, etc.)

ALL TREATMENT OlVEN UNDER MEDICAL SUPERVISION.

Quiet. Homelike. First-class Cuisine. Terms Moderate. Telephone 1851. Own Garage.
Prospecim from Miss Br&cksione* Manageress.

BATHS

Telephone 18 a, MINTO STREET,

3131. EDINBURGH.

THE INSTITUTION FOR PHYSICAL TREATMENT BY
MASSAGE, EXERCISES, ELECTRICITY, BATHS.

Established with the view that General Practitioners may give to their Patients the benefit
of treatment by the most modern methods of Hydro- & Electro-Therapeutics at Home.
A Class of Instruction in tlie Subjects named is conducted. Apply A. D. WEBSTER, M.D.

THE SPA, Tunbridge Wells.

C OMPLETE Installation of Baths, Douches, and all Forms of Hydro-
therapeutic appliances, Radiant Heat (Electric Light), Swimming,
Russian, Turkish, Vapour, Pine, Medicated and Foreign Baths, Nauheim
Treatment, Massage. Post and Telegraph Office on Premises.

Telegrams: “Spa.” Telephone: 56 Tun. Wells.

ADVERTISEMENTS

CRAIGLAMDS HYDRO,

= ILKLEY. =

Prospectus
and

Visitors' list
on

application
to the
Manager.

4 * 4 * 4 '

Resident Physicians: HENRY DOBSON, M.D., C.M.(Edin.), and
MAURICE R. DOBSON, M.B., B.S.(Lond.), L.R.C.P., M.R.C.S. (Eng.)

T he most popular Hydro in the district. Established over half a century.

Accommodates 220 visitors. Thorough Hydropathy, complete suites of
Baths, including Turkish and Russian. Magnificent Ball room, Promenade
Corridor, splendid Amusements,' elegant Smoke room, superb Billiard room (3
tables), pleasant Drawing room, Reading and Writing room, etc. Lovely
Grounds, 7 acres. 3 Tennis Courts, Bowling and Putting Greens.

Terms: £2 to 168. per week. Reduced Winter Tariff*

THEFRIW CHALYBEATE WELLS

The Richest SULPHUR-IRON WATERS known.

Protosulphate o£ Iron. - 381 grains to the gallon.

Prescribed for ANiEMIA, CHRONIC RHEUMATISM, SCIATICA,
GOUT, NEURITIS, DYSPEPSIA, GENERAL DEBILITY, &c.

PUMPROOM AND BATHS OPEN ALL THE YEAR.

Also supplied in perfect Spa condition for home treatment. Samples,
particulars, and guide free to the Medical Profession on request to Manager,
Trefriw Wells, Trefriw, N. Wales.

xi:..FX%..A.oo]y[BE; .

CLIFFE HYDRO HOTEL.

A MODERN HYDRO COMBINING THE ADVANTAGES OF A FIRST-CLASS HOTEL
Occupying an unrivalled position in well-wooded Grounds facing Sea. Billiards.
Electric Light. Fully Licensed. For those requiring treatment the Bath Depart-
ment is well up to date. There is a complete Installation of Electric Radiant
Baths, and every form of Electric Treatment, including Schnee's Bath, High-Frequency,
X-Ray, Galvano-Faradic, Ionic Medication, etc. The large well-appointed
Baths contain appliances for Nauheim, Pine, Sitz, Spray, Brine, and all Medicated
Baths. Massage, etc.

Physician : C. W. E. TOLLER.

A COli/lFORTABLE HOME for LADIES REQUIRING REST and DIET.
Officially appointed by R.A.C. •••• OWN GARAGE.

Telegrams: “ Hydro, Ilfracombb.” Nat. Telephone : 42. For terms apply: The Manageress.

ADVERTISEMENTS 879

endcliffe^hotel;

CLIFTONVILLE, MARGATE.

Facing Sea and Oval, occupying the finest position on the high cliffs. Sunny aspect.
Visitors will find this a Most Comfortable Hotel.

.. .. 60 Bedrooms and Suites of Rooms

ELECTRIC LIGHT THROUGHOUT. CORRIDORS HEATED.

Good English Cooking. Special Diet and every attention given to Invalids.
REDECORATED AND REFURNISHED.

Spacious Public Rooms, all facing Sea. New Smoking Room and Cloak
Room for Gentlemen on the Ground Floor.

FULLY LICENSED. Open all the Year. Thanet Golf Links within ea.sy distance.
Illustrated Tariff on application. Phone; MARGATE 54.

B. BOMPORD, Manageress date St, Ann*s Hotels Buxton.)

PROSPECT HOTEL. HARROGATE,

AND

MODEL BIJOU APARTMENT HOUSES,

FOR

Seif^Gontainetl Suites S Cure Dietary

Telegrams: “KUROTEL, HARROtiATK." G. M. BARTSCH,

Telephone: 1035, 1036. Manager.

TUMBRIPGE WEEES.

GRAND HOTElTcRoyal Kentish Hotel).

FAMILY AND RESIDENTIAL.

Facing Common, Near Ye Old Pantiles. Electric Lift. Garage.

Terms from £3 3s. per week. '

Tel. 162. J. R.. CLARKE.

FRANZENSBAD, Austria, the best

HOTEL KOPP K5nIGSV1LLA.

1 ■ '-::i Finest and best situation for taking fhe cure.

LARGE PARK. Tennis. Golf. All modern comforts. Lift. Electric Light;
Central hot-water heating. Suites with Bath and Toilet. Vacuum Cleaner. Splendid
Public Rooms. Auto Garage.

Telegraphic Address: KONlGSVtLLA, FRANZENSBAD.

ADVERTISEMENTS

MAI VETDIU hydropathic

mML.V d\IY ESTABLISHMENT

ONLY HOirSE IN MALVERN WITH ELECTRIC EASSENGER LIFT.

Superior.

Comfortable,

■ Excellent
Cuisine,
Separate
Tables,

Electric Light,
Sanitation
perfect,

Large Garden,
Tennis
and Croquet
Lawns,
Billiards,
Dark Room.

sew

r' , I s'jOii

|QriD?D.ii

Excursions and
other

amusements
arranged.

Baths include
every

Hydropathic
Appliance.

Massage,
Nauheim, and
all kinds of
Electric
Treatment.

Stands in own Grounds on the slope of the Malvern Hills and overlooking the beautiful

Severn Valley,

ILLUSTRATED BOOKLET SENT ON APPLICATION TO RESIDENT PHYSICIAN OR SECRETARY.

‘•HySfiiAU’ERN." Special Terms for Parties. Telephone 156.

Telephone 156.

British Camp Hotel.

WYNDS POINT, NEAR MALVERN.

THE HIGHEST SITUATED HOTEL IN THE MALVERNS.

Telegrams : “ Camp Hotel, Malvern Wells.”

FOR TARIFF—

HRS. F. jaNRS,

Proprietress.
Telephone No. 37 Colwall

L arge and spacious Dining Room with Separate Tables for Visitors. Large Drawing Room,
Smoke Room. The Hotel adjoins the residence of the late Jenny Lind. Motors and Carriages
to meet trains if desired. Accommodation for Motor Cars. Geologists, Botanists, etc., will find the
district surrounding the Hotel very interesting. Eastnor Park is within a few minute.s’ walk, and
Ledbury, Croome, and Worcester Hounds frequently meet in its vicinity.

The Hotel is within 3 minutes of the South Herefordshire Golf Link.s.

Motor Buses run periodically from Malvern to the ba.se of the British Camp all the year round.
Nearest Station : Malvern Wells.

ADVERTISEMENTS

88l

MALVERN

AN IDEAL HEALTH RESORT
For both SUMMER 81 WINTER.

Situated on the sunny slopes of the Malvern Hills.

AIR PURE AND INVIGORATING.

Hill Paths and Easy Gradients for

Cardiac Cases and Convalescents.

WATER OF RENOWNED PURITY,

MODERN SANITATION.

Famous Golf Links (9 & 18 holes). Fine Motoring Centre.
District replete with places of interest. Brine & other Baths.
3 Packs of Hounds. Excellent Schools of all’ descriptions.

ILLUSTRATED GUIDE BOOK sent Free on application to—

Secretary, Improvement Association, MALVERN.

WOODHALL SPA

BROMO-IODINE BATHS.

IPov Rheumatism, Gout, Sciatica, Uterine, Skin, and Nervous
Diseases, Nose and Throat Affections and Heart Disease.

The VICTORIA SPA BATHS, newly enlarged, comprise MINERAL, VAPOUR, PINEv
ELECTRIC, SULPHUR, and NAUHEIM BATHS, AIX & VICHY DOUCHE MAS-
SAGE, SCOTCH DOUCHE, BERTHOLLET VAPOUR, ROOMS for INHALATION,
LIVER, PACKS, the DOWSING HEAT and LIGHT TREATMENT. COMPLETE
ELECTRICAL INSTALLATION with SCHNEE BATH. GALVANIC SINUSOIDAL
and TRIPHASE CURRENTS, etc., X-RAY, HIGH FREQUENCY. IONIC TREAT-
MENTS, SWEDISH MASSAGE and VIBRO MASSAGE. Trained Attendants.

For particulars apply to LIONEL CALTHROP, M.B., L,R.C,P,f Med* Supt,
WOODHALL SPA, LINCOLNSHIRE* Tel. (P.O.) No, SO.

Mineral Water sold in Large Bottles at 12/- per doz. ; Concentrated
(** Mutterlange ”) for outward application only, 2/6 and 1/- per bottle;
(iranular Effervescing Salts, 2/- per bottle. To be had of all Chemists, or
direct from the Spring,' on application to the SECRETARY, WOODHALL
SPA CO, Ltd., WOODHALL SPA, LINCOLNSHIRE.

*ThA IflATAI^I A U ATCI Situated within its own extensive grounds, and contain
I 111# wlWIWfmIfm nviEilM jng jgQ Rooms, is replete with every comfort, atljoin?

' the SPA BATHS, and overlooks the PINK WOODt.

Electric liight throughout. Motor Garage. Tennis and Croquet.

Within s minutes’ walk of excellent i8-hoIe Golf Course.

Telephone : No. 25 P.O. Woophall Spa. For Terms apply THE MANAGER.

ADVERTISEMENTS

88.:;

*‘THE LEADING HOTEL.^' ~-z

PRINCE OF WALES HOTEL, SOUTHPORT

ON THE BOULEVARDS, LORD STREET.

Teiegi'ams: g Excellent Cuisine. Comfort. Moderate Terms. Great Golfing Centre^
So^Irthport. k Motorists’ Headquarters (R.A.C., A.A.,M.U.,R.C., etc.). FreeGarace
Telephone • ^ Shower Baths. Special Diet arranged for Invalids.

No. 1 5. HY. QASCOIQNBf Managing Director and Secretary.

SOUT HPORT (Bifffcdale Park).

Smedley Hydropathic

ESTABL-ISMIVIENT.

ELECTRIC TRAMS running from the House to Southport.

Recently added - New eail Room and Billiard Room.

Physician: JOS. G. G. CORKHITX, M.0.

Terms from 7 /6 per day. Russian, Turkish, Aix, Nauheim, and all other Baths.

FOR PRO.SPECTUS, APPLY TO THE MANAGERESS.

Telegrams: “Smedley, Southport.” Telephones 1 337 Mamagemcnt.

SOUTHPOliT: KENWORTHY’S HYDROPATHIC

A Residential Ilotol for Visitors for .shoit or long periods. A home for the CONYALESCEKT
Visitor desiring only rest and change, with every comfort. A PATIENT’S resort under pre-
scription of own medical adviser, or of the Physicians to the Hydro., to undergo Hydro- or
Ifllectro-Therapy. Suitable for Neuritis, Rheumatism, Arthritis Deformans, Neurasthenia,
Insomnia, Dial)ete.s, lironchltis, Constipation, Liver and Stomach and Renal Disorders. MASSAGE
TURKISH.Rnssian, Radiant Heatand Light (Dowsing), &o., Baths. STATIC. HIGH FREQUENCY,
and SINUSOIDAL ELECTRICITY. Massage— Manual, Vibratory, or Oscillatory. Sunny Aspect.
Near Entertainments. Dry, mild, clear, fashionable winter resort.

’Rhone 80. Telegrams: “ Kenworthy’s, Southport.”

Prospectus from Manageress or Dr. Kenworthy,

For COMFORT and HEALTH visit the

CATERHAM SANITARIUM and
SURREY HILLS HYDROPATHIC.

Charming country, bracing air, pure .soft water
and high elevation. Klectrle light and central heat.
Battle Creek system of diet and treatment. All forms
of baths, massage nnd Kle(? tricity, Welr-JUtcholl
rest cure. Trained nurses (male and female).
Resident Physician: A. B. OLSEN, M.D., D.P.H.
Telephone: Sii> Telegram: ” Hvniio,” Caterham,

DROITWICH.

AYRSHIRE HOUSE

PRIVATE BOARDING ESTABLISHMENT.

Pleasantly situated in CORBETT AVENUE, surrounded by a beautiful
garden and about 300 yards from St. Andrew’s Brine Baths, and quite close
to tbe Park .

The majority of the Rooms at AYRSHIRE HOUSE face S. and W. and
the Halls and Corridors are heated during the winter.

SANITARY ARRANGEMENTS PERFECT. CROQUET LAWN. TENNIS COURT & GARAGE.

lUustratecl Tariff on Application to the Proprietress: — Mrs. & Miss Reilly.

Telephone No. 37*

ADVERTISEMENTS

883

VALE OF GLWYD SANATORIUM

'PHIS SANATORIUM is established for the TREATMENT of

TUBERCULOSIS (pULM^lliyY^ FOlflWl)

as cai-ried out by Dr, Orxo Walther, of Nordrach. It is situated at a
height of 450 feet above the sea, on the sheltered aspect of mountains rising
to over 1,800 feet. The rainfall is small, being about 25 inches, and the sub-
soil is red sandstone. The atmosphere is consequently dry and bracing.

There are many miles of graduated uphill walks, similar in character and
extent to those at Nordrach, where the Physician was himself a patient under
Dr. Walther. The Sanatorium is situated in the midst of a large area of
park land away from main roads. Electric Lighting.

For particulars apply to —

GEORGE A. CRACE.CALVERT, M.B., M.R.C.S., L.R.C.P.,

Uanbedr Hall, RUTHIN, NORTH WALES.

Rucbury Sanatorium, ^

Osmothcrlcy, Northallcrtoiv, Yorkshire. i p" week.

Is situated on a siiiir of the Hanibleton Hills, for the Treatment in moorland air of Four
Consumptives and Two Neurasthenic or other Invalids— the former in revolvinj? sleeping
chalets and open-air quarters ; the latter in indoor quarters, with separate, and complete arrange-
ments for each clas.s. Specially adapted for good-class patients desiring the privacy and com-
forts of home-life under medical oai’e, with good nursing by two lady nurses, one being a trained
masseuse. Psycho-analysis by Freud’s method. Elevation 600 feet; south aspect, sheltered
situation, fine views and moorland walks, abundant sunshine, splendid air. and pure moorland
water. Resident Proprietor-H. B. LUARD, M.B.Camb., F.R.C.S.

Esiabtish&d 1899

MENDIP HILLS SANATORIUM

HILL GROVE, WELLS, SOMERSET.

OPEN-A IR TREATMENT OF CONSUM PTION.

Specially built, facing South. Extent of Sanatorium grounds 300 acres —
meadow and woodland. Sheltered pine avenues. Altitude 862 feet, magnificent
views for miles South. Hot-water Radiators and Electric Light. Electric Treat-
ment. Successful cures by continuous Inhalation. Graduated Exercises. Trained
Nurses. Resident Physician : C. MUTHU, M.D., M.R.C.S., L.R.C.P.

Author of “PuLMONARv Tuberculosis and Sanatoriu.m Treatment”;
a Record of Ten Years’ Observation and Work in Open-air Sanatoria.

Terms: 3 Guineas Weekly. Apply Secretary,

Malvern House Hotel,

ABBEY RD., GREAT MALVERN
First-dass Private & Residential

Specially adapted for
WINTER and SUMMER RESIDENCE.

Good Public and Priv'ate Suites. Large
Drawing and Smoking Room.s on Entrance
Floor. Electric Light. Bath Rooms (hot and
cold). Large shaded Garden. Tennis Lawn.
Sanitary Certificate. Paiticnlar Attention
given to Invulicl’s Diet,

Tel. No. 202.

Mrs. H. L. PERKINS, Res. Proprietress.

884

ADVKRTISEMENTS

THE

Home Sanatorium

WEST 80UTHB0URNE, Nr. BOURNEMOUTH

pOR Pulmonary Tuberculosis. Suitable climate Winter and Summer.

Skilled Nursing Staff including Night Nurse, Ten acres beautifully
timbered grounds. Croquet and Billiards. Charges 3 to 5 guineas
weekly. For illustrated prospectus and full particulars apply to

J. E. ESSLEMONT, M.B., Ch.B., Resident Supt.

Telegrams: “ Sanabilis, Bournemouth.** Telephone: 61 Southbourne.

Wenslepdale Sanatoriuiti

For the open-air treatment

OF CHEST DISEASES.

TERMS - - - £2 2s. per week inclusive.

T his sanatorium is situated in Aysgarth, Yorkshire : a district
celebrated as a holiday resort for its beautiful scenery, pure, dry and
bracing atmosphere.

It stands in three acres of ground 8oo feet above sea level, and is absolutely
remote' from manufacturing districts. Tuberculin is employed in suitable
cases.

PhVsicia^iS — D. DUNBAR, M.B. B.S. *

W. N. PICKLES, M.B., B.S.

A ddress — ^

THE SECRETARY, Wensleydale Saiiatorium, Aysgarth, S.O., Yorkshire.

RUDGWIGK SANATORIUM, SUSSEX.

QPEH^Am and BEST TREATMENT^

pure bracing air. Good Nursing. Generous Cuisine. Biii^le bedrooms only,
'rubereulin ''J’reatmeut (Dr. Camac Wilkinson’s method). Satisfactory results.
2.^ gruineas inclusive.

PRITTGK BEECHES, LONG STB ATTON; NORFOLK, for Visitors or Con-
valescents, at 2 guineas, or 25/- if willing to do light work. Revolving shelters and
chalets. Delightful walled garden. Tuberculin Treatment.

Apply— Dr. ANNIE Mc€ALU 165, CLAPHAM ROAD, LONDON, S.W.

KOSTHsHTTOR SAMATOPMUIH

J^ordrach in Irelarid. NEAR WARRENPOINT.

SPECIALLY BUILT IN 1899.

Three Miles, urhill from Rosxrevor Village on the Mourne Mountains.
Provided with Electric Li^ht, X Bay Installation, Verandahs, Revolving Shelters, etc.

OWM DAIRY AND POULTRY FARM. I ALL COWS TESTED BY TUBERCULIN.

TER MS per week: 3 GUIN EAS.

Ses. Physician— B. H. STEEDE, M.A., M.D., Gold Medallist : IVIud. Tr.avelling
Prizeman, &c. Ten Years Resident Physman Royal National Hospital for Consmnplion,

ADVERTISEMENTS

885

Alcohol and Drug Inebriety and Neurasthenia.

Invernith Lodge

COLINSBURGH, FIFE, SCOTLAND.

(Licensed under the Inebriates* Acts)

FOR GENTLEMEN ONLY. 1=1

Neurasthenia is treated on approved principles, and there are
Open-air Shelters in the grounds for suitable cases.

Inebriety and Narcomania are treated on definite medical lines,
and the most approved scientific means are employed in the curative
treatment. The Resident Medical Superintendent and his Resident
Assistant Medical Officer have each patient under their personal care
and observation. The curative treatment is much aided by the healthy
situation of the Sanatorium, and by its isolation from temptation.

The Sanatorium stands 450 feet above the sea, faces south, and
looks out over the Firth of Forth. The climate is dry and bracing. All
outdoor and indoor sports. First-class private golf courser. Excellent
mixed shooting over 1,600 acres, fishing, tennis, gardening, carpentry,
etc. Billiard room (two tables), music room, large private library.

Beferences to leading: Physicians in the
□ chief centres griven on application □

For all particulars apply to the

Resident Medical Superintendent - W. H. BRYCE, M.B., C.M.

Telegrrams : Telephone :

“ Saluhrions,’* Upper Jjargro. No. 8, Upper Iiargo.

Station :—Kilcon<inhar (N.B. Bailvray).

886

ADVERTISEMENTS

Tbe Alcobol and Drug Habits and Insomnia.

GHYLLWOODS

(formerly the GHYLL RETREAT),

Near GOGKERMOUTH, GUMBERLAND.

There Is atso a private postal address for patients* correspondence,

ircens^d under ihe Inebriates Acts. FOR GENTLEMEN ONLY,

P ATIENTS are here treated individually, and on a sound scientific basis, with the object of build-
XT in^ up the general health, strengthening the will power, and educating the mind to an adverse
attitude towards^alcohol and drugs. By their own and their friends’ desire patients can receive
treatment by Hypnotic Suggestion, a treatment now fully recognised-as of tbe greatest value in the
treatment of the above habits and of chronic insomnia, more especially when taken together with the
ordinary retreat regime, and, in skilled hands, entirely devoid of daugeiv

The situation of the house, in the heart of the Lake District, nine miles ‘from the
nearest Town and Railway Station, is unique in its suitability for this work, its isolation
making close confinement quite unnecessary in the vast majority of cases. Out-
door and in-door sports and occupations, including trout-fishing on own waters, golf (private 9-hole
course), tennis, &c. Workshop and dark-room are provided for carpentry, carving, photography,
&c., while the house contains a billiard table, and a large library is' subscribed to.

References can be given to well-known Medical Men in London and the provinces. Terms from
£3 3s., according to accommodation.

Full particulars on application to J. W. ASTtBY COOPBR, B.R.C.P., &c.,
licensee and Medical Superintendent.

Telegrams: ‘^Cooper, Buttermerc.”

INEBRIETY.

HOME FOR LADIES.
Voluntary or under the Act.

ASHFORD, Near Staines 1^1 Sol™”

B eautiful Residence, standing in its own grounds, 50 acres in extent,
^ Large Farm and Dairy. R* C. Chapel on the Estate. Terms, 12/6 to
Z guineas weekly. Particulars apply to the Mother Superior^

ADV^UTISEMICNTS

— — -

IN EBf^lETYm ALCOHOL AND DRUG ABUSE,

lEstablisbcti 1883, tbe ‘gjomcs fov 5ncbviatcg Bsgo:iation.

For the Treatment of tentlemen, under the /\ot and privately.

Large ^grounds on the bank of the river Colne, Gravel soil. Outdoor and indoor recreations
and pursuits. Half hour by train from London, TERMS ; From 3 guineas weekly.

Apply to Resident Medical Superintendent.

atoPiroNE : IS. BICKMANSWORTH.

Buntindford Bouse Retreat

BUNTINGFORD, HERTS.

UOENSEO UNDER INEBRIATES AOTS, JS79-99,

For Gentlemen suffering from Alcohol and Drug Inebriety ; also
for Gentlemen convalescing after illness.

In a most healthy part of the country, 18 acres of grounds, about 350 feet above sea level.
Electric Light throughout from private Installatioii,

Golf, Cricket, Tennis, Rifle Range, Croquet, Library,
Billiards, Photographic Dark Room, Gardening,
Open Air Bath, Carpenters’ Shop, Poultry, &c. &c.

Quarter mile from Station, G.E.R. TWO RESIDENT PHYSICIANS.

No Infectious or Consumptive Gases taken.

Inebriety Patients are admitted voluntarily only, either privately or under the Inebriates

Acts. Trains met.

An entirely new and up-to-date system of drainage and new baths and lavatories have
recently been added to the establishment.

TERMS FROM 2h GUINEAS,

Apply to Medical Superiatendent,

Telephone : Buntxngford 3.

Telegraphic Address: “Resident, Buntingpord.’

ADVKRTtSKMENTS

SS8

l>oine$ roFhieDriate men and VPoin^

The Church of £n^lan<l Temperance Society’s Institutions for those with slender means.

Chaplain-Sup, : JRisv. S. Scobeli. Lessey, M.D.

FOR 'ij^Easr-

ABBOTSWOOD HOUSE, CINDERFORD, GIo«cestersliire.

Private Room (when available), 2s. weekly. Terms : First-class, 30s. ; Second-class, 12/6 weekly

FOR "WOIVCBI^

Terms : ELLISON LODGE, HERNE HILL, S,E,

DrawinE-Room,2ls..25s.,aud ;£22s. ; Work-room, IDs. 6 t!., 12s. 6 d. and ISs. Kitchen, 7s. 6 d. weekly.

CORNGREAVES LODGE, ERDINGTON, BIRMINGHAM.

lerms ; Drawing-Room, 25se and £2 2s. ; Work-Room, 12s. 6d. and ISs. ; Kitchen, 7s. 6d. weekly.

Hamond Lodge, TetrringtQii St. Clement. King’s Lynn. Norfolk.

Terms ; Drawing-Room, 21 s,, 30s. and £2 2s. ; Work-Room, lOs. 6 d., 12s. 6 d. and ISs. ;
Kitchen, 7s. 6 d. weekly.

TEMPLE LODGE, TORQUAY.

Terms : Drawing-Room, 2 (s. and £i 2 s, ; Work-Room, 10s. Sd., 12s. 6 d. and |5s. ;

Kitchen, 7s. 6 s. weekly.

No Patient received for less than 12 months. No Female Patient over 60 years of aige admitted

^ Application for Forms and Particulars to : —

REV. GERAI 4 D A. THOMPSON, Secretary C.E.T.S., The Sanctuary, LONDON, S.W.

Inebriety. Drugs. Rest Cure.

NORTHLANDS RETREAT

20, BOUNGBROKE GROVE, WANDSWORTH COMMON, S.W.

Private Lincensed Home for ladiesm

Established 1864, Telephone No. : Battersea 1065.

Apply — T he Misses Round and Sister Reeve,

sidEow manor, rkigatb.

Under the Superintendence of LADY HENBY SOMERSET.

Patients Received lor Treatment of Inebriety and the Abuse of Drugs.

FOR LADtES ONLY.

LARGE GARDENS, BEAUTIFUL COUNTRY: EVERY COUNTRY HOUSE COMPORT.

Terms— From Two and a Half Guineas a Week.

Patrons*. Sir Thomas Barlow, Bart., M.D., Sir Lauder Brunton, Bart., M.D., Sir Bertrand
Dawson, 3SI.D., C. A. Mercier, Esq., M.D., Sir G. H. .Savage, M.D., Mrs. Scharlieb, M.D.,
A. T. Schofield, Esq,* M.D., Sir Thornley Stoker, M.D., Xiieodore Thompson, Esq.,
Leonard Williams, Esq,, M.D. information apply to the SISTER SUPT.

SPELTHORNE S. MARY & S. BRIDGET’S,

BBDFOHT, BBLTH&K, MIDDLESEX

Lioensed under the Inebriates Acts, 1878—1900.

Instituted for the Reform — Physical, Moral and Spiritual — of Women of the Upper and
Middle Classes. The House, to which a Chapel is attached, stands in beautiful grounds.
It is in the charge of Sisters of the Community of St% Mary the Virgin (Wantage)*

All communications to be addressed to the SISTER SUPERIOR^

THE GROVE RETREAT FOR INEBRIATE WOMEN,

FALLOWFIELD, near IIANCHESTEB.

Pleasantly situated in its own well-wooded Grounds of three acres, and
convenient to tram and train.

LICENSED UNDER THE INEBRIATES ACTS. RECEIVING 25 PATIENTS.
For terms and further particulars apply to THE MATRON •

ADVERTISEMENTS

889

MELBOURNE HOUSE

X.XSICSS'X'EIR.

PRI VATE HOME FOR LAD IES.

London Consultant : W. WYNN WESTCOTT, M.B., Coroner for N.E. London, 396, Camden
Road, Holloway, London.

Dublin Consultant : SIR WM. J. SMYLY, M.D., F.R.CP.I., $8, Merrion Square, Dublin.
Medical Attendant : ROBERT SEVESTRp:. M.A., M.D. (Camb?)

PrinciJ>al : HENRY M. RILEY, Assoc. Soc. Study of Inebriety.

Thirty years’ experience* Excellent Medical References.

For Terms and Particnlars apply Miss RILEY, or the Principal.
y'elegj-a^htc Address l.EICKSTKR.” Nat. Telephone I.E ICKSTER.

“fNEBRIETV AND THE MORPHIA HABIT.”

CAPEL LODGE RETREAT ^
SANATORIUM. .olkIsto^.

PRIVATELY OR UNDER THE ACT,

S ITUATED on the sunny cliffs overlooking the sea, is the only licensed
Retreat and private Home FOR GENTLEMEN on the South^ Coast.
The latest scientific methods are adopted for INEBRIETY and the
MORPHIA FI ABIT. Bracing sea air. Billiards, tennis, etc. 14 acres of
private grounds. CONVALESCENTS also received.

Terms : 3 to 4 sruinea.s weekly.

For- Prospectus apply NORTON, M,D*, Capel Lodge, near Potkestoae,^

BOOTH AM PARK, YORK.

A REGISTERED MENTAL HOSPITAL
for the Treatment and Care of Nervous and Mental
Invalids of the Upper and Middle Glasses

Fdr Particulars apply to the Medical Superintendent —

GEORGE RUTHERFORD JEFFREY, M.D. Glasff., F.R.C.P.E., F.R.S.E.

WEST MALLING PLACE, KENT

An old established Private Residence, entirely reconstructed, and adapted to the most
modern Systems (including open-air treatment) for the Care and Treatment of Ladies or
Gentlemen suffering from Nervous or Mental Disorders. Beautifully situated in the Hop
districts of Mid -Kent, an easy distance by Rail from London, Coast Towns, Sevenoaks,
Tunbridge Wells, Rochester and Maidstone. Terms on application to Resident Physi-
cian. Telegrams : Dr. ADAM, WEST MALLING.*’ Telephone : Mailing. 2.

Third Edition. 8vo. Bd. net,

QUESTIONS ON

SICK NURSING AND HOME HYGIENE.

By D. M. MACDONALD, M.D., D.P.H.

A CATECHISM ON HOME NURSING AND HYGIENE.

“ A bandy little compendium . . . will be found most useful for any one who is taking up the
study of sick nursing .” — Fi rst Aid.

Bristol: John Wriight & Sons Ltd,

London: Simpkin & Co. Ltd.

$90

ADVERTISEMENTS

Telegrams: “Dickson, Buxton.** National Telephone; 130, Buxton.

WYE HOUSE ASYLUM.

ESTABIylSHED IN 1858 , FOR THF

CARE and TREATMENT OF THE INSANE of the Higher and IVliddle Glasses.

The New Institution Completed tgor.

Kesident f GRffiME DICKSON. L.B.C.P. & S. Ed., L.E.F.P.S. Glasg., hied. SupL;

Physicians : t and ASSISTANT mSsdiOAL OFFICERS at Buxton and In N. Wales.
Chaplain ; Rev. Canon SCOTT-MONCRIISFP, M.A., D.D. (Vicar of Buxton and Rural Dean).

q^lllS Institution has been established for the Reception of Patients Of Both Sexes of
^ the Hig:her and Middle Classes, for whom it is admimbly adapted by its position
and appointments. It is erected on an eminence surrounded with scenery of the most varied
character, and tlie views from the House and Terraces extend over many miles of picturesque
country. There is also in connection a Summer Residence on the coast of North Wales. The
House is furnished throughout on the most liberal scale, and fitted up and arranged as a
Gentleman’s l*’amily Residence. Voluntary Boarders can be received.

The Sanitary arrangements and Ventilation are modem in design and perfect in construction,
and are certified to be .so by the Sanitary Authority.

The Medical Superintendent lives in the House, and is assisted in his duties by twp Assistant
Physicians, and an experienced I.ady Superintendent.

Every exertion is made to promote health and comfort, both by moderate bodily employ-
ment and by variety in amusements, such as reading, music, drawing, excursions, golf, billiards,
croquet, lawn tennis, theatricals, re-unions, etc. A library is provided, containing some 2,000
works of varied diaracter, suited to the condition of the patients ; also periodicals, magazines,
and newspapers. Motor exercise is provided.

Due provision is made for the spiritual welfare and consolation of the Patients, and Divine
Service is held every Sunday in the Institution.

The Pleasure Grounds, which are very spacious, have been laid out in the most tasteful
manner especially for the recreation of the Patients ; and contain conservatories, lawns for
croquet and tennis, a private ^olf course, and other out-door games ; also a theatre, two billiard
rooms, and workshop for the in-door occupation of Patients. The House is heated throughout
by means of hot-waler apparatus and open fireplaces.

Buxton is directly accessible bv the Midland and the D* & N.W. Railways. It is situated
on the mountain limestoue formation, 1000 feet above sea level. Being a watering-place, it
affords exceptional advantages and varied recreations to convalescent Patients.

Particulars of Terms and Forms of Admission on appUcaiion to The Medical Superintendent.

A 1 )V]vRTlSKMKNTS 89I

St. ANDREW'S HOSPITAL for MENTAL DISEASES

NORTHAMPTON.

For the Upper and Middle Classes, iasa. leiephoneos.

ThQ Hospital is ploaHantly sltuatctl in a high and healthy locality in heaiitifullv wooded

? :rounils, one mile from the Northampton Stations of the London and North Western and Midland
laliways. The journey from London to Northampton takes only one hour and twenty minutes.
The Hospital is suiTotmded by a large park and extensive pleasure grounds. Tlie object of the
Hospital is to provide treatment tor mental dlseasos, and aodouimodation and comforts for
liationls belonging to the upi>er and middle classes only, at moderate rates of payment. The
tormsof udmlsslou arc from one and a half guineas a week, according to the roQUirements of
the case. Vaikmts iiaying higher rates can have special attendants, private aimrtments, horses,
and carriages, motor cars, etc., either at the Hospital, or in detached villas la the grounds of the
Hospital, dr at Moulton Park, a branch establishment situated two miles from the Hospital in a
large farm of ntsarly 500 acres. The Hospital is supplied from this farm with farm produce such
as meat, milk and vegetables. Tliere are ample means of amusement, recreation, and oocupa-
lion, including golf, cricket, football, hookey, lawn tennis, crocjtuet, bowling, riding, driving,
boating, motoring, faimlng and gardening. Patients who can ride can be provided with horses,
or can keep their own at the Hospital stables. The Hospital possesses its own boathouse on
the river Nene, which flows at the Southern boundary of the grounds. Several billiard rooms,
and a large ballroom with 11 theatre, afford facilities for winter entertainments. The Hospital
is 10 minutes walk from the NortUamptonshlro County Cricket ground, and from Ablngton Park
where the best Military Hands perform during the summer months.

Bryn-y-Neuadd Hali, Llanfairfechan, N. Wales

<THE SEASIDE HOUSE OF ST. ANDREW’S HOSPITAL, NORTHAMPTON).

892 At)VERtISEMENTS

J5D#ll#ir a Private Home licensed by the commissioners in
##fclWi£#€/lw Lunacy for 14 Ladies Mentally Afflicted.

T he house is very easily reached, either by the Hampstead Tube to Golder’s
Green, or by motor bus (from all parts of London) which pass the gates.
Established over 60 years, the house has been completely modernised, and
all the equipment is up-to-date. The Medical Officer and Proprietor is resident,
and the whole surroundings are made as home like as possible.

The Home
stands in its
own grounds
of 15 acres,
300 ft. above
sea level, and
is provided
with its own
poultry and
dairy farm;
all milk,
butter, eggs,
poultry and
veg etables,
etc., being of
home p r 0 -
duce.

Tennis, croquet, motoring, carriage drives, and varied in* and out-door amusements.
The fees vary from £5 5s. Od. per week inclusive.

Ali coimmmicaiions to be addressed to —

The Resident Medical Officer and Proprietor,

*Phone 764 Finchley, Hendon Prove, Hendon, N.W.

BETHNALL HOUSE ASYLUM,

Cambridge Poad, LONDON, N.B.

FOR THE INSANE OF BOTH SEXES.

Terms on application.

J. KENNEDY WILL, M.A., M.D., Resident Medical Superintendent.

dtp or Condon mental hospital.

Under the management of a Committee
of the Corporation of the City of London.

4%-

Hear DARTFORD, KENT.

Private Patients are received at the inclusive rate of One Guinea per week
'^mwards. An illustrated booklet giving full particulars can be obtained
Medical Superintendent. The institution is within two miles of
^\mtion on the S, E. Railway, and is about 16 miles from London."

MENTAL HOSPITAL

^^TSMOUTH.

Nijded for LADIES and GENTLEMEN in
>ly opened, at a charge from &1 11s. 6d.
pt pl othing.

SUPERINTENDENT.

ADVERTISEMENTS.

893

for the

treatment of mental Diseases.

SHAFTESBURY HOUSE,

FORM BY -BY -THE -SEA,

Telephone: No. « FORMBY. Nsap LIVERPOOL.

IResl&ent Xicensccs:

STANLEY A. GILL, B.A.. M.D.. M.R.C.P. Lend.,

Formerly Medical Superintendent to the Liverpool Lunatic Asylum.

EUSTACE STANLEY HAYES GILL, M.B. Ch.,

Liverpool University.

T. R. GLYNN, M.D.. F.R.CP.Lond.,

Constdiing Phys. Liverpool Infirm. y & Profi of Med. Univ. Coll. Liverpool.

CouBultfua Surgeon.;

W. THELWALL THOMAS, F.R.CS.Eng., M.S.,

Liverpool University.

HIS House, specially built and licensed for the care and treatment
of a limited number of Ladies and Gentlemen mentally afiBicted.
is delightfully situated near the coast between Liverpool and
Southport, so that patients have the benefit of pure bracing sea air,
for which Formby is noted. The House is in the country, and stands
in several acres of ornamental well-wooded grounds, the surroundings
being in every way bright, cheerful and pleasant. As the Licensees
reside on the premises they are able to devote the whole of their
time to the constant supervision of the patients. All kinds of out-door
and in-door amusements and occupation provided. Voluntas*>^Boarders
without certificates admitted.

TERMS MODERATE - Apply MEDICAL SUPERINTENDED

The Licensees have also a Private Residence at Llanj
Wales, for the treatment of mild borderland and conjj

Dr. STANLEY GILL and Dr. HAYES GILL
30, RODNEY STREET, LIVERPOOL, £ro:
— Monday and

S94

ADVERTlSIiMENTS

STRETTON HOUSE,

CHUR CH STRETTOM, SHROPS HIRE.

A Private Licensed House for the treatment of Gentlemen
suffering from Nervous or Mental Diseases.

ESTABLISHED I8S3.

S ITUATED amongst charming scener3% more than 600 feet til3ove the
sea, large grounds, pure water, perfect sanitation, and enjoving the
bracing air of the “ English Highlands.”

Easily accessible from all parts. Good train services on C.W. and
U. & N.W. Railways.

Congenial occupation and i*ecreation are specially attended to, and
all sorts of indoor and outdoor ainiiseinents are provided.

Patients have carriage exercise and daily walks amongst the beauti
fill mountain scenery.

For Terms and Further Information, apply to —

THE MEDICAL SUPERINTENDENT.

Telegrams: a; Telephone:

“ Stnetton House, Church Stretton." 10, Church Stretton.

Kingsdown House,

BOX (Near BATH).

Telephone: No. 2 Box.

LICENSED FOR THE TREATMENT OF DISEASES
OF THE BRAIN AND NERVOUS SYSTEM.

'JpHIS House is situate 450 feet above sea^ level, and commands
extej^sive views of the surrounding country.

^^ccess Box Station (G.W.B.) ; Bath Stations (Midland
twenty minutes from the house.

sidcjit Proprietor & Medical Siiperinteiidenf,
at the ahozYi

Telephone * No. G3(), Hath,

ADVERTISEMENTS

895

Ne w SaugMon Hall,

PRIVATE HOSPITAL for the Treatment of NERVOUS & MENTI^L CASES.

MEW SAUGHTON HALLy whlcli takes the place of Sausliton Hall, established In 1798, is situ-
ated seven miles south o£ Edinburgh, in the beautiful neighbourhood of Hawthornden,
and Ilosslyn, and is surrounded by picturesque and %velbtimbered pleasure grounds extending
to 125 acres. There is also a SEASIDE HOUSE at GULLANE, EAST LOTHIAH.

Eailway Stations.— Polton five minutes ; and Loanhead, ten minute'.’ walk from the Insti-
tution-reached in half-an-hourfrom the Waverley Station, I'ldlnbursih. Telephone : i Loanhead.

Forms of Admission for Voluntary or Certified Cases, full instructions, etc., can be obtained
on application to the Besident Medical Sunerintendent, j. BATTY TUKE, M.D., F.R.C.P. Ed.

Inclusive Terms from jESA to per annum, according to requirements.

BETHEL HOSPITAL

FOR MENTAL DISEASES,

NORWICH.

ESTABLISHED A.D. 1713.

T his institution is an endowed Hospital, registered under the Lunacy Acts,
and managed by a Board of Governors who have no pecuniary interest in
its success, but whose sole object is to promote the comfort and well-being of
the Patients, The Hospital is arranged for both sexes.

The terms for admission are thirty shillings per week, or more, according
to Patients* condition and circumstances, which includes everything, except
clothing, carriage exercise, or any expenses incurred for amusement beyond
the Hospital grounds.

CONSULTING PHYSICIAN:

SAMUEL J. BARTON, M.D.

(Senior Physician io the Noifolk and Noi-wich Hospital)*

Rbsidsnt Medical Superintendents

SAVILLE J. FIELDING, M.B.

Clerk to the Governors s

FRANCIS HORNOR, Queen Street,

Matrons

Miss OXLEY (Late S/stei’ Guy’s Hospital,^

Application for Adiussion to

Resident Nledical Superintendent!

896

ADVERTISEMENTS

BOREATTON PARK

T his private ASYXvUM, which was founded by the late W. II. O.
Sanicev, M.D., P\R,C.P., for the reception of a limited inmiljer of

Ladies and Gentlemen MENTALLY AFFLICTED,

is now conducted by his son,

B. H. O. Sankey, M.A., M.B., B.C. Cantab.

The I/adies’ Division is directly supervised by Mrs. Sankry.

The Mansion stands high, among handsomely laid out gardens in the
midst of a picturesque deer park (about 70 head of deer are kept), atid
commands a magnificent view of Welsh mountain scenery.

Carriages, horses, motor, lawn-tennis, golf, trout and other fishing
are provided.

Arrangements can be made to enable friends of patients to reside in
the House as Boarders if so desired.

The Asylum is situate about ten miles from Shrewsbury, within easy
distance of Baschurch Station, G.W.R., whither carriages can be sent at
any time for visitors.

Letters and Telegrams should be addressed to —

DR. SANKEY, Boreatton Park, BASCHURCH, SALOP.

THE MOAT HOUSE,

STATIONS: L.&N.WEST. & MIDLAND RAILWAYS. a HOH

TAM WORTH,
dCij STAFFa

A HOME for NERVOUS
and MENTAL GASES.

Tho Houfie Bhands in ffroiindH of
ton acres (within 5 minutes' drive
of either Station, and in devoted 10
the care and treatment of a few
Ladles sufferlnf? Nervous and
Mental DisorLlers, who onjjoy the

PRIVATE PATIENTS in a detached Villa,
with the County Asylum at Lancaster, but
department.

per week, without extras.

-SUPERINTENDENT,

ADVERTISEMENTS

897

Telegrams: “ENVOY, FINSQUARE, LONDON.” Teleplrone: 5608 Central.

St. Luke’S Hospital

For Mental Diseases,

^DMISSION on payments up to 42/- per week. In certain
' circumstances Patients are received gratuitously.

Convalescent Establishment at St. Lawrence-on-Sea, Thanet.

Country Convalescent Establishment, near Gerrards Cross,
Bucks, standing in 130 acres of Park,

Ornamental Gardens, and Grounds. ::

VOLUNTARY BOARDERS ARE received at the
:: Hospital and Convalescent Homes. ::

Trained Nurses supplied from the Private Nursing Staff
for nursing Mental and Nervous cases at their own homes.

Full particulars on application to ^ W. H. BAIRD,

the Secretary at the Hospital, Secretary.

Established 1826.

PECRHAM HOUSE

112, PECKHAM ROAD, LONDON, S.E.

Telegrramss “Alleviated, London.” Telephone: 1576 Hop.

An Institution licensed for the CARE and TREATMENT of the MENTALLY
AFFLICTED of Both Sexes. Conveniently situated. Electric trams and
omnibuses from the Bridges and West-End pass the House. Private houses
with electric light for suitable cases adjoining the Institution. Holiday parties
sent to the Seaside branch at Worthing during Summer months.

— Moderate Terms: —

Apply to MEDICAL SUPERINTENDENT for further particulars.

ISLE OF WIGHT ASYLUM.

Z' I.A.1DY PRIVATE

A DETACHED Residence for Lady Private Patients is now in occupy
in connection with this County Asylum.

The building is beautifully situated in the centre of the island, in ^
healthy climate, and fitted with the electric light and other m<

Provision is made for amusement by dances, concerts, etc.n j
and treatment. . . - ” .

TERMS:— from 21/^^mBBKl

Appy\ to the Medical Siipcrintcndcm

WHITECROFT, CAR!

ggS A DVERTISEMENTS

ESTABLISHED 1314.

NORTHUMBERLAND HOUSE,

GREEN LANES, FINSBURY PARK, N.

Telephone No.: 888 North. Telegrams: “Subsidiary,” London.

An INSTITUTION for the Care and Treatment of Ladies and
Gentlemen suffering from Nervous and Mental Affections.

Four miles from Charing Cross ; ^ nearest Station, Finsbury Park (G.N.
and N, London Railways) ; Tubes to City and West End. Electric Cars
from Finsbury Park Station run every few minutes past the gates.

Six acres of ground, highly situated, facing Finsbury Park.

Private Villas, in suites of rooms.

Voluntary Boarders received without certificates.

Seaside branch at Worthing.

For terms and other particulars apply to RESIDENT PHYSICIAN.

HOLLOWAY SANATORIUM

VIRGINIA WATER.

A Registeped Hospital for the CURE and CARE of the IKSANE and of
HERYOUS INVALIDS of the MIDDLE and UPPER CLASSES.

T his institution is situated in a beautiful and healthy locality, within
easy reach of London. It is fitted with every comfort. Patients can
have Private Rooms and Special Attendants, as well as the use of General
Sitting Rooms, at moderate rates of payment. Voluntary Boarders not
under Certificates can be admitted. There is a branch establishment at
Canford Cliffs, Bournemouth, where Patients and Boarders can be sent for
a change, and provided with all the comforts of a well-appointed home.

For Terms, apply to the Resident Medical Superintendent,

St. Ann’s Heath, Virginia Water, SURREY.

THE RETREAT. YORK. ^^^abushbo

A Regristered Hospital for the Treatment of Mental Diseases.

TTiiacr ilip management of a Committee of Members of the Poclety of Friends. Sitnalod
aoonl, Uvo miles from York Station. The Patients are derived from the Upper and Middle
Classes, and none are paupers or rate-aided. Terms from 48/- weekly.

\ oiimt.iry Hoarders are received on their own application.

partienlars sec the Annuiil Report, which will be sent on application to Dr.
X-jKncj.;, the ]\reaie.al Superintendent. A-a<. Telephone.: 112 York.

TH ROX E N B Y H A LlT^N^ SCARBOROUGH.

With The Thdreat, York, situiiited near the liaimdiife Woods,
kktwii *^!‘'*'^'horou!;di, f<»r tlie iveepthm ef Convalescent Patients, iilso for lln^

Incipient or mild forms of Mental Disorder u im e.aimoi.
'L'ln.sfimid odiid, and who wish voluntarily to plii.ee tijonisel ves luidm' sUiliod
- .riner particulars ap])ly to tlie iUatrun, or to In;. Hiun'oitn PiKin'K, at Tin:
J eit-pfumt' ; 282 Scarborough.

trained nurses departivient.

Imvi! i,raini‘(l for four yours in t ho Ib^trosti, and cun-

AlKN’rAL and Niiinvous ('asks om1,> midortaKi-n.

10;;. 0(i. \u'ek!y

Apply MATRON, Retreat, YorK,

Nat. Tel. 11

ADVERTISEMENTS

SPRINGFIELD HOUSE

Near BEDFORD.

(TELEPHONE No. 17. Within an hour of London by Midland.)

An Institution for the

CARE AND CURE OF THE INSANE.

Under the Personal Direction of the Licensees:

DAVID BOWER, M.D.

(Laie Resident Medical SnJ^crintendeni of Saughion Hall Ai^ylum Edmlnirgh ;)

Mr. W. S. bower and Miss BELLARS,

(ASSISTED BY LADIES’ AND GENTLEMEN’S COMPANIONS.)

DR. BOWER attends at 5, Duchess Street, Portland Place, W., on Tuesdays,

from 4 to 5.

tTcviiis tlbrce (SiUncas pcv wecFh

Including’ separate bedrooms for all suitable cases.

Vacancies are advertised each week in the British Medical Journal and

the Lancet.

CAMBERWELL HOUSE,

33 PECKHAM ROAD, S.E.

Telegrams: '‘PSYCHOLIA, LONDON.” Telephone: New Cross 1 057.

For the Treatment of MENTAL DISORDERS.

Completely detached Villas for Mild Cases. Voluntary Boarders re-
ceived. 20 acres of grounds. Cricket, tennis, croquet, squash racquets,
bowls, and all indoor amusements. New Chapel under construction.
Ordinary Terms, 2 guineas a week.

Full Particular,'! from the SECRETARY.

Senior Physician : FRANCIS H. EDWARDS, M.D.. M.R.C.P.

HOVE VILLA, BRIGHTON — A Convalescent Branch of the above.

CLARENCE LODG^

CLARE NCE ROAD, CLAPHAM PARJ?^

A limited number of LADIES suffering from MENTA^gj^^
DISORDERS are received for treatment under a specialisy^'^
in large grounds.

For further Particulars see Illustrated Prospectus^

Telephone: 494 Brixton.

900

advertisements

BARNWOOD HOUSE,

GLO UCESTER .

A REGISTERED HOSPITAL for PRIVATE PATIENTS
Only, of the UPPER and MIDDLE CLASSES.

A RRANO-ED and fiiniislied with all the most approved appliances foi
the treatment, comfort, and amusement of the Inmates. Within two
miles of the Railway Station, and easily accessible by Rail from Eondon
and all parts of the kingdom. It is beautifully situated at the foot of the
Cotswold Hills, and stands in its own grounds of 250 acres.

For ierinSi apply to JAS. GREIG SOUTAR, M.B., C.IVI.,
TELEPHONE No. 307 . Resident Superintendent

PLYMPTON HOUSE,

PLYMPTON, SOUTH DEVON

ESTABLISHED 1834.

P lyYMPTON HOUSE is licensed for the accommodation of both sexes,
and is well adapted by its position and appointments for the medical
treatment and care of Patients of the Upper and Middle Clavsses, suffering
from MENTAL DISEASE.

The proprietors, Dr. Ai<fked Turnkr and Dr. J. C. Nixon, have had
very large experience of Mental cases, both in public and private institu-
tions, and everything that can be done to ameliorate the condition of the
chronic, and promote the cure of the acute cases— placed under their charge
— ^is guaranteed.

TERMS ON APPLICATION. Letters and Telegrams:

Telephone: No. 0 PLYMPTON. DR. TURNER, PLYMPTON.

OTTO HOUSE.

47 , North End Road, West Kensington, W.

Telejthone: No. 1004 Hammersmith

A HOME FOR THE CARE AND TREATMENT OP LADIES
MENTALLY AFFLICTED.

Appl 3 ^ to Mrs. Chapman (Resident Lady Superintendent), or to
A. H. SuTHKRisAND (Licensed Propr.), 2a Marloes Road, Kensington, W,

W LANDS HOUSE,

. Tooting Bee Common, London, S.W.

^OME for the Care & Treatment of a limited number of
jig from NERVOUS or MENTAL BREAKDOWN.
^tlars apply to Dr. J. Noel Sergeant,

PROPRIKTOR AND I^L-SimCNT PuVSfCfAN.

ADVERTISEMENTS

901

Incorporated by

Royal Charter.

James S^urray's
Jioyal %/lsylum, S^evth.

Chairman — The Rt. Hon. The Raii of Mansfield.

'T'HIS Asjjluin, for Private Patients only, is beautifully situated in the immediate vicinity of
* Perth, in the midst of extensive Pleasure (Irounds, which are surrounded by the fields of the
Home Farm.

The Main Building has been entirely re-organized and enlarged by the addition of tivn zvhigs, for
the reception of acute cases, so as to render it an efficient Hospital as well as a comfortable Home,

The Mansion-House of PiTCULtEN, Sf.ven Gables, Elie, and The East and West Vili.as,
afford the necessary variety; of accommodation for modern treatment. Consumptive Patients are
separately treated in Sanatoria^

Consulting Physician : Dr. URQTJHART. a; Telephone No,

Physician Superintendent : Dr. DODS BROWN. '* 104, Perth,

ASHWOOD HOUSE,

KINGSW INFORD, STA F FORD SHIRE.

An old-established and modernized Institution for the Medical Treatment
of Ladies and Gentlemen Mentally Afflicted.

T he House, pleasantly situated, stands in picturesque grounds of forty
acres in extent, with a surrounding country noted for the beauty of its
walks and drives. The climate is genial and bracing. Occupation, indoor
and outdoor amusements, and carriage and other exercise amply provided.
Terms vary according to requirements as
to accommodation, special attendance, etc.

TELEPHONE, lo, KINGSWINFORD.

Railway Stations : Stourbridge Junction (G.W.R.), 3I miles ; Dudley (L. & N.W.R.), 4 miles;
Wolverhampton (G.W.R. or L. & N.W.R.), 7 miles. Intending visitors can be met at any of these
Stations.

Fok further i’articulars apply to the medical SUPPiRINTF.NDKNT.

NORTHWOODS HOUSE,

WINTERBOURNE, near BRISTOL.

A Sanatorium for Ladies and Gentlemen suffering from
Nervous and Mental Disorders.

OITUATED in a large Park, 300 feet above sea level, in a healthy and^
O picturesque locality, easily accessible from London, Bristol, and Car^"'"'
by Winterbourne Station ; or from Fishponds, Yate, or Patchway Statit^

Voluntary Boarders received without Certificates.

For further information, see London Medical Directory,

Terms, etc., apply to Dr. J. D, THOMAS, Resident
Northwoods House,

Dr. liYiOyikS attends at PARK ST.
on Mondays and Thursdays^ from
TELEPHONE No. i!

902

ADVERTISEMENTS

MIDDLETON HALL,

MIDDLETON ST. GEORGE, near DARLINGTON, Co, DURHAM.

PRIVATE ASYLUM FOR THE CARE AND TREATMENT
OP LADIES AND GENTLEMEN.

TTHE HOUSE, which .stands amid well-wooded grounds, in a healthy and pleasant country in
* the valley of the Tees, has been recently erected from plans approved by the Commissioners
in Lunacy, and embodie.s all the late.st improvements in the construction of Homes for the Nei\ous
and Mentally Afflicted. The building is fire-proof, and lighted throus;hout by Electiicuy, and
the heating Ls aided by a system of steam pipes. Private sitting-room« and sj-itcial attendants are
provided if required. Voluntary Boarders, not under certificates, can he icceived.

Terms to he had on application to L* HARRIS-LISTON, Medical Supt.

ASHBROOK HALL,

HOLLINQTON, ST. LEONARDS-on-SEA.

A first-class Private Home, charmingly situated in the midst of a garden of
nearly three acres, approached by a private road. Twenty minutes by tram from
either Hastings or St. Leonards (Warrior Square) Stations, Licensed tor the
reception of six Ladies mentally afflicted. Voluntary boarders received.

A good small house adjoining grounds for Borderland Case.

Consulting' and Visiting Physician : — ,

Dr. LIONEL WEA'rHERLEY, ISa Upper Brook Street. Grosvenor Square. London, W.
and VVinsIey House, Stourwood, Bournemouth.

for further particulars and terms apply to

Mr. & Mrs. CHARLES SOMERSET, Resident Licensees.

NOTTINGHAM.

HOSPITAL FOR MENTAL DISEASES.

President- The Right Hon. EARL MANVERS.

This Institution, fiir the receptiun of Private Patients of hnib ,se.\cs of the Upper and
Middle Classes only, at moderate mles of payment, is beautifully situated in its own gmumls
about two miles from Nottingham, a.Td from its singularly healthy and pleusaiU position, and tin;
comfort of its internal arrangenienls, afford.s every facility fur the lelief and cure of those tneiiially
afflicted. Divine .Service is held in the Institution every Sunday by the C^haplain, who aKo visits
the Patient.s. Can'iage exercise is provided.

For Terms, Etc., apply to

Dr, HUNTER, Physician-Superintendent.

COTON HILL

3Vi:3E33\rT-A.Iji JEZOlSPX'X'^lLi

Nbak STAFFORD.

i- htii) inmi of the Connniftee of Jl/iinai^einrn / —

n-IT HONOURABLE THE EARL OF DARTMOUTH.

^icii IS ))u.iiiiilnllv . situated ill .a hinli am! lieallhy pnsitiuii, with esletisivt*
'..Trt'u Tunnis Courts, (Jolf Lillies, etc., is dcvoicfl In the C.\rk anij
[^i.v Ai'i-'iuiia» OK THE U'n’Eu and Midiu.k C'l. asses.

'i.'l.iiiis ill the Ilospii.il, or senibdcUiclted Villas in the

npplicution.

HEWSON, L.R.C.P. & S. Ed. (Ed. Univ.) Med. Supt.

ADVERTISEMENTS

903

THE WARNEFORD,

HEADINGTON HILL, OXFORD.

A Registered Hospital for the Care and Treatment of both Sexes of the Upper
and Middle Glasses, when suffering from ^ervous and Rlental Disorders.

President— Tim Right Hon. THE EARE OP JERSEY.

Chairman of the Committee —

The Rev. WIEEIAM ARCHIBALD SPOONER, D.D., Warden of New CoUege, Oxford.
Ftce-C7miman— S urgeon-General Sir A. FREDERICK BRADSHAW, M.A., K.C.B.

The Regular Charge for Patients is £2 2s. a week, but tlie Committee have power to alter
the charges at their discretion, as tlie circumstances of cases require.

The building is arranged, so far as is compatible with the requirements of a IMental Hospital,
in the manner of an orcHnary private residence.

The Hospital possesses an Endowment Fund, arising from nnmerons grants of the late Dr.
Samuel Wilson Warneforu and others. When a reduction of the ordinary charge is asked, a
special statement of the circumstances of the Patient must accompany the application for
Admission.

For farther particulars, apply to the Medical Superintendent, JAMES HEIL, M.D.

THE GRANGE, Near ROTHERHAM,

A SANATORIUM OF THE HIGHEST CLASS FOR THE

CARE «[ CORE OF SIENTAL ISYAllDS (LADIES).

Consulting Physician : CROCHLEY CLAPHAM, M.D., F.R.C.P.E.
Resident Physician : G. E. MOULD, M.R.C.S. Eng., L.R.C.P. Lend.

Physician for Mental Diseases to the Sheffield Royal Hospital::

“TTHE House is a spacious Family Mansion, with extensive pleasure grounds, induding good
A Croquet and Tenuis Grounds, aird an immense Park, containing Private Drives and Walks of
several miles in extent. It is situated in the heart of the famous Robin Hood Country (5 miles
from Sheffield, 4 from Rotherham) and is surrounded by beautiful scenery, and an atmosphere
free from smoke and impurity. Situation dry and healthy. The arrangements are of a domestic
character. The Proprietors welcome visits from the usual Medical Attendant of the Patient during
her residence. Under the New Act Voluntary Patients can be received, without Certificates, on
own personal application. The Rev. R, T. C. Slade, Mus. Bac., Vicar of Thorpe-Heslcy, acts as
Chaplain, and conducts regular Services.

The Resident Physician may be seen at the Grange; or at EeavylreaYe House,
Hounsileld Road, Sheffleld, by appointment. (Nat. Tel. »o, 34, Rotherham.)

GRANGE LANE STATION (M. S. & E. Railreay) is within a quarter of a mile of The
Grange, and may be reached via Sheffield or Barnsley direct ; or via Rotherham, changing at Tinsley.

For Terms, Forms, &c., apply to THE RESIDENT PHYSICIAN.

CRANBOURNE HALL

GHOUVIELE, JERSEY.

MENTAL AND INEBRIATES’ HOME FOR
.= LADIES AND GENTLEMEN. ==.

Medical Superintendent — ^A. C- STAMBKRG, M.D.

Old established, and delightfully situated in the most healthv
picturesque locality in the Xsland. Voluntary Boarders receivech^ppF
certificates. Terms — 2 to 6 Guineas a week.

For further particulars apply to —

MISS TAYIiOR, Lady Superin^
or to the Medioal Snperintgji^

904

ADVERTISEMENTS

PRIVATE ASYLUMS.

CO. DUBUIN.

t(AniPSTE/^D, Clashevin, for Gentlenien j ((IGHFIELD, Drumcondra, for Ladies.

For the Cure and Care of Patients of the Upper Class suffering from
Mental and Nervous Diseases and the Abuse of Drugs.

Telephone No. 1032* Telegrams: “ Eustace," Glasnevin.

These Hospitals are built on the Villa System^ and there are also
Cottagres on the demesne <154 acres), which is 150 fti above the sea level
and commands an extensive view o-Fthe Dublin Mountains and Bay.

Voluntary Patients admitted without Medical Certificate.

For further information apply for illustrated prospectus, etc., to the Resident Medical
Superintendents: Dr. Henry Marcus Eustace, Hignfield, Drumcondra, or Dr. William
Nielson Eustace, Hampstead, Glasnevin; or at the Office, 41, Grafton Street, Dublin,
Telephone 198. On Mondays, Wednesdays, and Fridays, at s.30 p.m.

ESTABLISHED 1824.

The Retreat Private Asylum,

NEAR ARMAGH.

For the CURE and TREATMENT of Ladies and Gentlemen of the Upper
and Middle Classes suffering from

MENTAL AND NERVOUS DISEASES.

Voluntary Boarders and Inebriates admitted without Medical Certificates.

This Retreat is beautifully situated in picturesque grounds of 150 acres, and Patients enjoy tlie
■ greatest possible liberty. There is a large percentage of Recoveries on recent admissions.

For particulars apply to the Resident Medical Superintendent,
Dr. J. aOWER ALLEN, J.P.

FARNHAM HOUSE GENTLEMEN I MARYVILLE LADIES

MTEAlR x>xrsx.lliiir.

Private Hospitals for Patients of tlje Upper Glasses suffering „ Te?e//ii»tc—T>i\Uim 1470
from NERVOUS and MENTAL DISEASES, ALCOHOLISM, Etc. Fmfu.As."

CoNSur.TiNG Rooms: 4t, Upper Fitzwilltam Street, DUBT.IN (Tek]fi/wie: Dublin 2867).
'T’HKSE Establisbment.s, which are healthily situated in pretty grounds upwards of 59 acres In
t extent, provide modern medical curative and palliative treatment on motlerate tfsnns.
Wiluniary Koardens admitted without Certificate.s. Large .Staff maintained. TTp-tO'dale
sanitation.

A SEPARATE WINQ hn.s been set ap,art for the Treatment of ALCOHOLISM
and DRUG HABITS, with their own reception rooms and grounds.

Prospectus and Terms on application to—

H. P. D’ARCY BENSON, M.D., M.R.C.P., F.R.C.S. (Edin.), Resident Medical Supt.,
Parnham House, FINGLAS, DUBLIN.

Derby Borough Asylum.

FEMALE PRIVATE PATIENTS.

^RATE and DETACHED BLOCK has just been opened. Terms:

per week, which includes everything except clothing.
■jljLdistinct from the main Asylum, and has separate recroaticni

^itlars, (xfiply to the Medical Superintendent,

R. MACPHAIL, Rowditch, DERBY.

ADVERTISEMENTS

IN CHARMING COUNTRY, NEAR LONDON.

Littleton Hall, Brentwood, Essex.

HOOJEET above sea level).

A HOME for a few LADIES MENTALLY AFFLICTED.

Larf?e grounds. _ Villas. London 18 miles (easy motor run)!
Liverpool Street hall-an-hour. Stations. Brentwood one mile;
Shenfield one mile.

For Tenii.t, particulars and forms of admission, etc., apply
Dr. Haynes. Telofhone and Telegraph: Haynes, Brentwood 45.

tibe Xawn, Xincoln.

A REGISTERED HOSPITAL FOR MENTAL DISEASES,
situated in the City of Lincoln, near to the Cathedral.

FOR TERMS, APPLY TO

DR. RUSSELL, Resident Medical Superintendent,

I^IVKRPOOI., E.

P RIVATE ASYLUM for the Care and treatment of Ladies and Gentlemen
MBNTALI.Y AFFLICTED. Voluntary Boarders also received without
cert i Heat cst

Pot terms (tpi>ly to : J. J. TISDALL, L.R.C.P, & S. or [Resident Medical
F. B. INOALL, F.R.C.S. Eng. 1 Super mien dents.

I : .] UPLANDS I ' I

A I n rtf A riAtnrhp/l Vilin in connection with Cheshire County Asylum,
A Large ueiacnea yum, Macclesfield, for the reception of PiuvAtE

Patients of both Sexes. FeKvS from £l Is. upwards, according to accom-
modation, Apply for JT'nspectus to —

J. C, McCONACiHBY, M.D., Medical Superintendent.

Telephone: Macclesfield 17.

BRISTOL; JOHN WRIGHT

go6

ADVERTISEMENTS

STOKE PARK COLONY

For Mentally
Defective Children,
STAPLETON,

BRISTOL.

Apply to Secretary — National Institutions for Persons
requiring Care and Control,

14 Ho wick Place, Westminster, S.W.

Telephone: 3045* Victoria. Telegrams: ** Burdensome. London.”

¥ ROYAL ALBERT INSTITUTION

LANCASTER.

The ROYAL ALBERT INSTITUTrON is a Home for the Care, Education and Training
of the Improvable Reeble-IMimded, witli accommodation for 750 cases.

Terms : i. Free Patients, between the ages of Six and Fifteen, whose friends cannot meet the
lowest payment of 35 Guineas per annum.

2 . Paying Patients admitted by the Central Committee without Election and
at any time. The charges vary from 25 to 200 Guineas per annum.

BRUNTON HOUSE (For Private Pupils).

BRUNTON HOUSE combines the comforts of a Private Plome with all the advantages of a
large Public Institution under responsible management. It possesses extensive gardens and grounds
which include tennis and croquet lawns. Individual attention is given to the pupils by an expe-
rienced Staff, under a Resident Physician and Lady Matron. SAMUEL KEIR, General Secretary.

St. 6eorgc’s Retreat, burgess mii, sdssex,

'T’HIS PRIVATE ASYLUM is under the Management of An^stinian nuns. It receives Lady
*■ Patients only, who are under the immediate care of the Sisters. A Chaplain and a Medical
Man reside in the house, and the patients are also visited regularly by a physician of special
experience. The establishment is supplied with every requisite for the treatment and well-being of
the Patients ; and the grounds (of 2S0 acres), in which it stands, afford ample space for their
recrejition and e.xercise. It is within two miles of Burgess Hill Station, on the London and
l^rightou Railway, and is ea.sily accessible from all parts of the kingdom.

For particulars and terms apply to The REV. MOTHER SUPERIOR, ST. GEORGE’S RETREAT.

MERRISON,

DORCHESTER ASYLUM,

Thi.s Home for Private Patients is delightfully situated, with all modern
convfuic.'nce's for the treatment of the Insane. Terms on application to the
IMIi.J)JCAL SU PEKINTENDENT, Herrison, Dorchester.

Telegrams: “Herrison, Charminster,’*

ILVER BIRCHES,

Church Street,
EPSOIVI.

^ been established over 60 years for the Care
Ladies suffering from Mental Ailments.

^MS, Hie., on tif>/flicuihn to —

rra.^ce, or to Dr. It, C. Daniel, Co-LicciiH'e.
346 P.O. Epsom.

ADVERTISEMENTS

GOLD MEDAL INTERNATIONAL MEDICAL EXHIBITION, LOHDON, 1913
THE SKEFFINGTON. ^

Sits iHitioiit ui), eliany’os ils
Sheet.

Lifts Saoniin for Changing
]>raw Sheet.

Lifts for Making Bed
Underneath.

CAN BE HIRED.

THE ANASTASIA.

Ifold the Hhoet s^.s at A. Fasten the clamps C 0. Turn the handles and Wlieels from Bed to Bed
the sheet assumes the shiums B B, tha patient only having to lie still.

THE SKEFFINGTON LIFTING
CUSHION.

Lifts for Bed Pan in a Wide Bed as easily ns in a
Narrow One.

THE SKEFFINGTON
FRACTURE MATTRESS.

Lifts Patient and gives access to Sglue.
Hiohest AWAun, -rijw

SiSC'IMON

CoiJi.\rsKD.

BoYAI. BAmTAItY XN.STITir^TE,

Biuoni’ON, 1910.

(told Medal, Vienna,
Cold Medal, Gr.\nd
Prix, Mil.vn.

THE

SKEFFINGTON

INOLINATOR.

Section

An JESTED.

Gold Medal, Grand
P.\LA i, Paris.

THE SKEFFINGTON SACRUM UFTER I

3 Under the Bed. ijifts Sacrum tor Changing Draw Sheet.

Used at Edmonton Infirmary.

Slips on to any bedstead.
Adopted by the
London Hospital.

Tt>legrams : Rincalift, London.
Telephone ; 1:>96 Retc Cross.

SKEFFINGTON’S

49, ULUNDi ROAD, BLACKHEATf>^^^|tfl^

9o8

ADVERTISEMENTS

ALLEN & HANBURYS Ltd.

Maiccj's of Surgical Instruments and Aseptic Hospital Furniture

The New
“Wigmore’^

Surgeons’ and
Midwifery Bag

Bag, Surgeon’s or Midwifery, A. & H.’s latest improved design,

The ‘*Wigmore,” made throughout of solid black grained pig-
skin. The upper compartment is fitted with an aseptic remov-
able and washable lining. The lower compartment is made to
accommodate a Steriliser eitlier 16 or 17 in. long, and is supplied
with a removable unpolished mahogany rack, fitted with five
2 oz. best hand-made glass stoppered bottles : complete with bots. £2 17 6
Improved Portable Instrument Sterilizer, to fit above £1 5 6

Portable

Tuberc ulin Case

As suggested by
Dr. Hyslop Thomson

Complete in leather
covered case
£3 11 6

Full particulars of
above on application

xgmore Street, Cavendish Square, London, W.

ADVERTISEMENTS

909

ALLEN & HANBURYS Ltd.

Makers of Surgical Instruments
and Aseptic Hospital Furniture

Registered Pattern
No. 606095

This apparatus is a great improvement on that invented by Br.
Hamilton Irving. It allows the patient to sit comfortably, prevents any
puddle of urine collecting at the bottom of the protector or shield, has
only one opening for the rubber tubing instead cf two, and the belt and
adjustments are much more comfortable.

Complete Appai*atus fitted with India-rubber Under-straps £1 6 6

Do. do. Tape Under-straps ... £1, 4 0

Copeland’s Stethoscope.

Complete with Copeland’s Registered Chest Piece
Localizer for above, 2/6 each.

48 , Wigmore Street, Cavendish Square, London, ^

gio

ADVERTISEMENTS

D OWN B ROS/ S PECIALITIES

New Portable Outfit for
Intravenous Injection of Salvarsan,
Neo-Salvarsan, Etc.

Suggested by Mr. A. ALLPORT, M.R.C.S., iTon. Surg., St. PauTs Hospital.

The following advantages are claimed for this compact
Outfit : —

1. It can be carried to the patient’s house sterile, and

ready for use.

2. The tap, being of glass, does not corrode, and backward

flow of blood, or the possible entry of an air bubble
can be seen.

3. The apparatus rests firmly on the bed, and no assistance

is required throughout the injection,

PRICE

The Complete Outfit, with Sterilizing Drum and Outside
Waterproof Cover, £5 0 0

If with Platinum Iridium Needle, 3/9 extra.

f IRAN ns RR!X:

Paris iQofi, l*i;us‘~.i;i idio, Uurkos Aihils igio

DOWN BROS. Ltd.

Surgical Instrument Makers,

21 8c 23 St.Thomas’s Sh, London, S.E.

i«)i*posni-. f.uy’.s 11< >spnAr.i.

7 e/f'ri iiw:; : 7 i'/c'j'honi s ,*

“DOWN. Hon. 4400 (4 lines)

LONDON.’*

ADVERTISEMENTS

91 I

D OWN B ROS/ S PECIALITIES

An Improved Portable Apparatus for the
Intra-tracheal Administration of Ether.

Made after the Design of Mr. R. E. KELLY, M.D., F.R.C.S., Liverpool.

Securing many ad-
vantages in Thoracic:
and General Surgery,
in Thoracic Surg-
ery, obviating the
need for positive or
negative cabinets. In
Mouth, Nose, and
Throat Operations,
avoidance of risk of
inspiration of blood,
mucous, or pus.

In Goitre Opeja-
tions, air is supplied
below the Tracheal
obstruction.

Etherization Apparatus.

In Head and Neck
Operations, the anes-
thetist is well away from
the surgeon.

Owing to the slight
respiratory movements,*
operations on the upper
part of the Abdomen are
considerably facilitated,

A most efficient appara-
tus for inducing artificial
Respiration,

Rotary Blower with Electric Motor.

PRICES

Etherization Apparatus, complete in Mahogany Case ... £17 18 6

Blower, complete with Motor, for use with alternating current 15 15 0

Do. do. continuous current 14 7 0

Foot Bellows, for use where electric current is not available ... 2 0

GRANDS PRIX :

Paris 1900, Brussels 1910, Buenos Aires 1910,

DOWN BROS. Ltd.

Surgical Instrument Makers,

21 &23 Si. Thomas’s St., London, S.E.

(Opposite Goya's Hospital),

Telegt'ams :

** DOWN,
LONDON

Telephones :
Hop. 4400 (4 n

912

ADVERTISEMENTS

D OWN B ROS/ S PECIALITIES

AN IMPROVED AUTOMATIC
ABDOMINAL RETRACTOR.

As made for Mr. HAROLD CHAPPLE, M.C., F.R.C.S., Guy’s Hospital.

iSL

Designed to give
a suitable exposure
of the field of opera-
tion under all cir-
cumstances. Self-re-
taining. Enlarging
readily in either
direction. Blades
can be attached, re-
moved or altered in
position or inclina-
tion at \sil].

Price, with 4 Detachable Blades, £5 10 0
Additional Fenestrated Blade, extra 18/6

grands PR IX :

Paris 1900, Brussels 1910, Buenos Aires 1910.

DOWN BROS. Ltd,

Surgical Instrument Makers,

21 & 23 Si Thomases Si, London, S.E.

(Opposiris Gvv’i^ lIu.snrAL).

f aius : Tch'^/nvtes :

“DOWN, Hop. 4400 (4 lines)

LONDON.”

ADVERTISEMENTS

913

D OWN B ROS.’ S PECIALITIES

Improved Suspension Laryngoscopy Apparatus

As made for 'Mr. W. G. HOWARTH, F.R.C.S., Surgeon Throat Department,
St. Thomas’s Hospital, etc.

A modification of Prof, Killian’s Instrument, comprising, with other advan-
tages, mouth gag with wider opening, adjustable counter-pressure plate, extra
long spatula, and improved swing with swivel joint. Designed to secure the
most perfect access and comprehensive view.

Prick : —

Complete Apparatus, with set of 12 Spatulse ... £20 11 9

GRANDS PRIX;

Paris iqoo, Prussels iqio, Buenos Aires 1910

DOWN BROS. Ltd.

Surgical Instrument Makers,

21 & 23 St. Thomas’s St., London, S.E.

(Opposite Guv’s Hospital).

Telegrams:

“DOWN.

LONDON.”

914

ADVERTISEMEN TS

Special Catalogues
sent on request.

Static Electricity,
X-Ray Tubes,
Carbon DUoxide

Snow,

Bergonie Obesity
Apparatus,

Multostat and

Politherap
Universal Machines,

Fon Hot Air Douche,
X-Ray Apparatus,

The ‘‘ Safety ”
X-Ray Apparatus.

Specially devised
for Municipal
C Units.

Prof. B ergon ie’s
New Method
of

TREATING

OBESITY

1 1 'ith iJie necessary mod ijt cat ions for ireating—^

CARDIAC DERANGEMENTS (Hampson’s Method), MUSCULAR DISORDERS, and
CONDITIONS BUB TO DEFICIENT ELIMINATION,

Fiiied xoiik ojtr Patent AIeiro>iotm\ electrically controlled^ y*ermitting
of ahsolnte accuracy, silence, and greatest range of adjustment. , ,

SEND FOR NEW DESCRIPTIVE CATALOGUE.

The attention of the ^Tedical Profession is directed to the striking results obtained by
Doctors 7/sing our Bc/gonie AJJaratus,

Within will be found the Reports from —

Dr. Humphris in cases of Obesity; Dr. Hainpson in Crirdiaq Derangements.^

A Dr. of Bournemouth, .states : “ In cases of Obesity the patient jn every ease feeling stronger
fur the treatment, while losing 3 to 4 lb. weight per week, while cases of Cardiac (Jvlejna
lo,st up to as njuch as 9 lb. of fluid after the first treatment of 20 minutes* duration, whilst
rhe pulse -was, reduced in frequency and became more regular,”

PLEASE CALL AND SEE THIS DEMONSTRATED, OR LET US CALL ON YOU.

\OTE. — KxH'ry successful 7‘eco?d of tJte Berganie treatment in this country has been produced

vrth nhfiaraius sujbf>lied by the Medical Sz/tph Association.

Address for Telegrams and Cables : ^ fres/en> VAou Telcohone N,,s ( 0';nTkai..

“ORtSVILUTE, LoNUON.” and Vri cat,' Codes > ■‘•^‘cpnonc xm-s. | 2999 Hoi. oOi.'N.

The MEDICAL SUPPLY ASSOCIATION,

X-RAY

Actual Manufacturers of

ELECTROTHERAPEUTIC

APPARATUS.

Head Offices and Showrooms: 167-173, GRAY’S INN ROAD, W.C., also at
31, South Ann Street, Dublin \ 12 , Holly Street, Sheffield

12, Teviot Place, EdInburAb i, Newport Road, Cardiff

56, Sauchiehall Street, Glasgow I 24, Collej^e Square, E. Belfast

ADVERTISEMENTS

925

THE MEDICAL SUPPLY ASSOCIATION,

^ Address: 167 & 173, CRAY’S INN ROAD, LONDON, ENGLAND.

GrevilHte, London.” also at

Edinburgh, Glasgow, Dublin, Sheffield, Cardiff, and Belfast.

For use
over
Fire or
Gas

Burner.

Macdonald’s “Gold Medal”
STEAM STERILIZER

(Patent Nos. 5S81 and 1317.)

l—Cheap and Simple. 2— Efficient for Dressings
and Instruments. 3— pressings made perfectly
Dry and Aseptic. 4-~The small amount of steam
evolired allows its use in any room.

Germs are all destroyed in less than half an
how. All that is necessary is to pour in re-
aulsite amount of water, place in dressings,
adjust lid, and set on gas-ring, fire, or other
heating apparatus.

B No. ‘1. — Polished Copper,
tinned inside, internal di-
mensions of sterilizers, 6Sin.
deep X in. diameter.
Complete, with nickel* plated
copper drum, size iu-
" 6 in. each £2 17 6

Do., nickel-plated 3 3 0

No. 2. — Polished Copper, tinned inside, internal dimensions, 9 § in.
deep X 9 Jin. diameter. Complete with one nickel-plated drum,
size 9in. x 9in. ... ... ... each £4 17

Do., do., do., nickel-plated ... ... each 5 5

No, 2A. — Do., do., internal dimensions, 20in. deep X 9J in. diameter.

Complete with 2 drums, 9in. x9in. ... ... each 7 10

Do., do., do., nickel-plated ... ... each 8 10

Prices of larger sizes on application.

Full particulars on requesU Sterilizers sent out on approval if desired.

STERILIZING CASE AND CARRIER

For holding knives, in Antiseptic Bryistele Solution.

Case and Carrier for 2 knives, 5/-; for 4 knives ... ... each 7/6

Scalpels, forged solid, best English ... ... ... „ 1/6 & 2/6

Symes* or Paget*s Knives ... ... ... ... „ 2/- & 2/9

Brytstele preserves the lustre of all steel instruments, and keeps the edges
of blades sharp.

THE “ SURGMAN ” No. a

HIGH PRESSURE (S) STERILIZER

FOR DRESSINGS, Eto.

WITH VACUUM ATTACHMENTS, Registered and Patent applied for.
Renders Dressings, etc., absolutely Sterile and dry in 30 minutes at
the cost of a few pence.

Automatic.

Si mple to us e.

Portable.

Reasonable in price.

Handsome in appear-
ance.

Made of stout copper
and gun metal, and
supplied with safety
vah'e, water gauge,
taps, etc., stand with
bunsen burner, and
one nickel plated im-
proved model drum
which will hold 2 over-
alls, 6 towels, and suffi-
cient dressings for any
major operation.

Diameter outside ... 11 ins.

Height to lid with stand 23 ins.

Size of drum ... 104 ins. high by 74 ins. across.

Price of Sterilizer complete on stand with bunsen burner and one
nickel plated drum to contain the dressings, etc. £6 10 0

Extra drums 20s. each.

EVERY STERILIZER IS
CAREFULLY TESTED
BEFORE PACKING.

Applied pni?.

froRiOreatPortlanii S% OPEN DAY Sc NIGHT 3 Mir\utes front Oxford Circus

917

Aseptic Cabinet (or Instruments, etc.

8123 CABINET FOR INSTRUMENTS, etc., white enamelled
steel, with plate glass door, sides and back, with lock and key,
on stand with drawer and plate glass shelf underneath, and
rubber-tyred casters as illustrated.

No. l~Sii;e of cabinet 18 x 14 x 8 (2 plate glass shelves) £4 10 0
No. 2 — Size of cabinet 24 x 18 x 1 1 (3 plate glass shelves) £5 0 0

No. 3 — -Size of cabinet 25 x 20 x 12 ditto £6 0 0

Without drawer, 10/. less. With iron back instead of plate glass,

7/6 less.

8125 CABINET,
for Instruments,

& Dressing Table,
combined, com-
plete as illustrated,
with 8 boxes of lint,
wool, gauze, band-
ages, etc., swing
bowl and tray, slid-
ing shelf underneath,
bin for soiled dress-
ings, size of cabinet
23xl9xllJ with'"
3 plate glass shelves, ^
plate glass sides and
door, lock and key.
'Fhe whole mounted
^ on large rubber-
tyred casters, total
height 63 inches
£6 6 0

2Door$frc(inOreat*PortUi\iiSt, OPEN DAY& NIGHT

91 8 AnVKKTtSl5MKNTR

A NEW SYRINGE

AI«E METAE (30 cc.)

FOK

LOCAL ANAESTHESIA

As used by SIR BERKELEY MOYNILIAN and Dr. G. \V. CHILE.

PRICE, comDlete in Metal Case, with SchlmmePs Nee<ileB and Adapter^ 25$,

This Syringe has been specially designed for the administration of Quinine
and Urea, and Novocaine according to Crile. It is, however, equally adapted
for the injection of any solution.

A distinct advance in the tecjinique of injection.

CHAS. F. THACKKAY

Surgical Instrument Maker ^ EE EDS.

UXBRIDGE ROAD, HAYES, MIDDLESEX.

list' free

Sanatoria Specialist.

ALSO MAKERS OF

Motor Sheds, Glass Houses, Studios, &c.

7 ft. x7 ft.. S.6 10s. Od. I 8 ft. x«ft., £8 Ss. Od.
Revolving Gear, 10s. extra.

FUNERALS. CREMATION. MONUMENTAL MASONRY.

The London Necropolis Company

Funerals in Town or Country at moderate Inclusive charges.
AitendamGB mny hour, day Oi* nig Mm
Head Olf^ces ; 121 Westminster Bridge Road, London.
Telegrams: ** NecropolOi London.** Telephone: Hop 839.

JOHN WRIGHT 8L SONS Ltd., BRISTOL

Medical Publishers and Printers.

Cataloliues
8c Samples
Fi'go,

ADVERTISEMENTS

919

A New Portable
Operating Table

'J'HIS table is mainly constructed of an alloy of aluminium
combining strength and durability with lightness.

It is easily unfolded and erected. The lifting movement is
carried out in finest quality steel.

WEIGHT. — 24 lbs. ; with Accessories and Case, 34 lbs,

SIZE. — In position, 6 ft. long, 18^ ins. wide, 33 ins. high ;
folded in case 41 ins. long, 23 ins. wide, 5i ins. high.

Foot and head
pieces are
quickly fixed at
any angle.
Trendelenburg
position is
automatically
obtained by ^
turning handle
shown in
illustration.

Cost of Table, complete with Stirrups, £15 15s. Od. Case 30s. extra.

CHAS. F. THACKKAY

Sur cjical Instrument Maker,

LEED

920

ADVERTISEMENTS

THE HOLBORN

Surgical Instrument Co. Ltd.,

26 , THAVIES INN, HOLBORN CIRCUS,
LONDON, E.C.

Telegpsiphic Address — Telephone No.

“AMPUTATION. LONDON/' 1450 HOLBORN.

THE “HOLBORN

UNIVERSAL SALINE INFUSION APPARATUS.

For Continuous Proctoclysis. For Subcutaneous Infusion.

Suggested by

N. STUART CARRUTHERS, M.R.C.S. Eng., L.R.C.P. London.

Vide B, M. J., 30th Sept., 1911: — “The Inefficiency of the
present method of Saline Infusion."

We claim the follo'wing advantages for this
Apparatus : —

It is of simple construction, easily put to-
gether, and inexpensive. The Solution re-
mains hot in the vacuum flask for at least
6 hours. The amount infused is clearly
shown by the water gauge and graduations
at the side of the container. A uniform
temperature can be maintained and the rate
of flow controlled by means of the regulating
taps.

For Continuous Proctoclysis, with Canny Kyall’s
Dropper and Rubber Rectal Tube - - £1

Ditto, with additional fittings for Subcutaneous
Infusion > - - - - 2

Adjustable Suspension Rod and Clamps for fixing

to Bedstead - - ~ - extra 0

Thermometer with Glass T-piece and Rubber
Cork ----- extra 0

PiTmphlct on application (mention Medical Annual),

^22

ADVERTISEMENTS

the: DIASCOPE

MODEE 1913.

„ For .

X-Ray Examination
1 of Throat, Lungs, and

Stomach of Children
and Adults.

Localisation
and Examination of
; Suspected Areas in
Pulmonary
Tuberculosis.

More than One Hundred of
these Diascopes have been
supplied to County Councils,
Education Committees,
Local Authorities and Gen-
eral Hospitals.

An Auxiliary of Dean’s
Ringworm Apparatus work-
ing in conjunction and from
the same source of supply.

ENTIRELY
BRITISH WORK.

itory iHimpfilets, etc., to

4^. DEAN

STREET,

MOON.

ADVERTISEMENTS

The “Brompton ” Sputum Pot

(PATENT)

t MARCUS PATERSON,

As supplied to the leading Sanatoria
\\ I c =2 throughout the Country, c rz.: ,t

Made in aluminium, cheap,
STERILIZABLE, SELF-CLOSING,

Can be used with one hand— Unspiilahle.

“Emandum”

Electric

Examination Lamps

For Throat, Nose,

Ear, and Eye Work.

As supplied to the

LONDON COUNTY COUNCIL SCHOOL
CLINICS, Welsh National mem-
orial TO King Edward vu, and

the leading Throat HosjutaU in Great Britain.
Over 1000 now in me.

fnil Particulars tm app/icatim to--

Mayer & Meltzer,

. MANUFACTURERS OF .
SURGICAL INSTRUMENTS.

71 GREAT

LONDON,

: MKt.BftUHNK, Ol'8

924

ADVERTISEMENTS

U C A DCAM ’C CDC#^I A I lYI CC Used in all the Bacteriological Laboratories in the
nCMLfmOUni O wrCvIMtlUl l ICiO World, and by all Medical Officers of Health,

itew Combinaiion Incubator, with
tubes for opsonic, and tray for
Wasserman work.

Electric Centrifuge 15 o.o. conical
tubes, 3 ,<)(}() r.p.m. adapted to
any current and voltage.

Hcarson’s Patent Biological
Incubator, heated by gas,
oil or electricity.

PAnTlCULABS AND PRICES Q.V APPLIOAT JON.

HEARSON & GO. Ltd., Bacteriological & Pathological Apparatus Manufacturers

235, KKGENT STREET, LONDON, W.

MADAME EGARTE

lla, ORCHARD ST., PORTMAN SQUARE,

I^ONDON, W.

Ladies’ Surgical and Maternity Corsets and Belts,

Patients attended at their homes, and Doctors’ instructions carefully observed.
Perfect fit, comfort and durability assured. Strong reliable Corsets and
Belts for Hospitals at contract prices.

ADVERTISEMENTS

925

. THE

GATHGART STERILIZER.

Edinburgh Royal Infirmary,

Time serves but to confirm the
super-excellence of this Sterilizer.
None other can touch it either in
certainty of operation or in ease
of manipulation. Its moderate
cost places it, in that respect also,
before all others.

The steam enters the chamber
from the bottom, but, by means
of a special two-way tap, is not
allowed to enter until the contents
liave been sufficiently heated to
expel all cold air and to prevent
condensation.

The Sterilizer can be used with
or without Casket (see below), and
gives dry dressings, absolutely
sterile.

It can be used over gas bnnsen,
Primus stove, electric heater, or
even on a coal fire.

It is made of heavy copper, tinned inside, in two sizes, holding
respectively one or two caskets, 10 inch size.

Prices : To hold One Casket - £2 0 0

To hold Two Caskets - £4 0 0

<ht receipt of remittance, Carriage paid within the United Kingdom. ^
Colonial and Foreign Orders, f.oJ). any British Port. Full dircctioti
xcith each Sterilizer.

CASKETS : ]\lr. Catucakt's Special Caskets, heavily
recomm<!n<1(?.d. 'riieir shuttered upenings, extra large and nur
lid and bottom.

Pkicic, each - 22 /-

Waterproof Canvas Cover with Strap, for carrying Caskey
Price, each m

ARCHD. YOU

' BANDAOr;, JvDIi

SURGICAL INST

(Supi)lying

to 61, Forr

ADVERTISEMENTS

Gamgee Tissue

This Dressing, introduced by us, and of which we are the sole
proprietors and manufacturers, is deservedly increasing in favour
witli the profession. We quote the following extract from a
clinical address delivered by SAMPSON GAMGEB, Bsq., B.B.S.E.,
Consulting Burgeon to the Queen’s Hospital, Birmingham.

On purely surgical ju'ouncla, I have no hesitation In stating that the ahsorhenfe
OauiKe and Cotton Tissue, prepared at my suggestion by Messrs. Robinson &
Sons Ltd. of Chesterfield, Is the most generally useful and comfortable, the
most easily manageable and moat economical surgical dressing with which I
am acaualnted.

V The Tissue, as made in long lengths, is perfectly uniform in surface and
thickness and can be cut to any shape or size to pad tho trunk or the limbs.
In case of disease or Injury. Powerfully absorbent and elastic, the Tissue, is
ciiually serviceable for drainage and compression, for dressing blisters and
burns, wounds and ulcers, sprains and fractures. The Tissue docs ixot lump
together, but remains uniform, and la a most soothing and healing application
to inlimned joints and many skin affections.

'* The Tissue is susceptible of any antise^io medication, and It also takes up
plaster of Paris cream, liquid glass, collooioh, or paraffin so readily as to form
an excellent basis for splintage and moulds. A limb or the trunk may be very
speedily and effectually immobilized by surrounding It with h layer of the
dry Tissue, and outside that placing a layer or intersecting slips of the same
material, previously soaked fii iikister of Paster cream or other solidlfiablc
substance”— which is best kept in its desired position by Robinson & Sons’
Absorbent Bandages,

When ordering^ this Dressing^ insist on the
packet bearing; the words CAMGEE TISSUE,*’
many imitations, irrefi^ular in thickness and
inferior in quality, being: on the market under
the name of* Ootton Wool and Gauze Tissue.

Capsicum Tissue

Made from onr well-kiiowu Gamgee Tissue, charged with tho
active essence of Capsicum aucl Methyl Bal icy late,
distinctive feature of onr Manufacture is tho combination
of Methyl Balic-ylafce with the napsicum.
i^aingce Tissue is found to be a much more convenient
the Capsicnm, etc., than ordinary ahsorhout Cotton
fiends itself more readily for application to the parts
affected.

1-lh. rolls, or cut to any size required. We
artons and labels free from stamp duty,
you in cartons ready for sjile.

mpias anti Pi*ioQS»

|d.. Chesterfield

street, EX.

Indian Agricultural Research Institute (Pusa)

LIBRARY, NEW DELHI-110012

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